NCLEX QUESTIONS how to care for her mother appropriately.

Which nursing
diagnosis is most appropriate?
(1) Social isolation
1) The nurse makes the following entry on an elderly client’s
(2) Powerlessness
care plan, “Goal not met. Client refuses to ambulate, stating, ‘I
(3) Situational low self-esteem
am too afraid I will fall’”. The nurse should take which of the
(4) Altered role performance
following actions?
(1) Notify the physician
5) A 76-year-old client is admitted to the hospital. The nursing
(2) Reassign the client to another nurse.
assessment yields the following problems. Which of these
(3) Reexamine the nursing orders.
problems is related to aging?
(4) Write a new nursing diagnosis.
(1) Hyperopia
(2) Conductive hearing loss
2) Which of the following nursing diagnoses would most likely
(3) Presbycusis
be associated with the absence of hair on a 70-year-old male
(4) Tinnitus
client’s legs?
(1) Altered nutrition: less than body requirements.
6) Pain in the elderly requires careful assessment because older
(2) Risk for infection
people have which of the following characteristics?
(3) Fluid volume deficit
(1) Increased pain tolerance
(4) Tissue perfusion, altered: peripheral
(2) Decreased pain tolerance
(3) Are likely to experience chronic pain
3) A nurse is preparing to complete an admission assessment
(4) Experience reduced sensory perception
on a client that is partially hearing impaired. The best approach
would be to do which of the following?
7) A nurse is working in a geriatric screening clinic. The nurse
(1) Request that a family member be present.
would expect that the skin of the normal elderly client will
(2) Prepare written questions that cover the assessment criteria.
demonstrate which of the following characteristics?
(3) Speak slowly in a low-pitched voice while facing the client.
(1) Dehydration causing the skin to swell.
(4) Perform the physical assessment only at this time.
(2) Moist skin turgor
(3) Skin turgor showing a loss of elasticity.
4) An elderly, terminally ill client is being cared for by her
(4) Overhydration causing the skin to wrinkle
only daughter. The daughter expresses a fear of not knowing
8) A 78-year-old visually impaired client is admitted to the
nursing unit. Which of the following interventions would be
most appropriate in reducing sensory deprivation?
(1) Close curtains to reduce glare.
(2) Keep doors open to provide bright light into the room
(3) Keep curtains open to allow the sun to shine brightly in the
room
(4) Keep lights in the room dimmed.
9) Which of the following are associated with the aging
process. Choose all that apply.
(1) Increased visual impairment
(2) Increased calorie requirements
(3) Decreased sensation to heat and cold
(4) Decreased subcutaneous fat
Which of the following is an accurate
description of a frail older person?
A frail older person is one who is independent
in minimum activities of daily living.
A frail older person is one who has a
noticeable planned weight loss of 10 pounds in
a year.
A frail older person is one who exhibits
dependence in several activities of daily living.
A frail older person is one who experiences
frequent periods of depression.
A frail older person is one who exhibits dependence in one or more
activities of daily living. This dependency often restricts ADLs, and
limitations in ADLs can contribute to feelings of depression.
Which of the following factors are most
likely to exacerbate risk for disease and
frailty? (Select all that apply.)
Loss of appetite and delirium
Sleep disturbances and failures of self-care
Poor lifestyle choices and poverty
Iatrogenesis and dizziness
Risks for disease and frailty increase with age, and can be
exacerbated by poor lifestyle choices and poverty.
Which of the following groups of older
persons is more likely to have limitations
in ADLs when chronically ill?
Caucasians are more likely than African-
Americans to have limitations in ADLs when
chronically ill.
Native Americans are more likely than
Caucasians to have limitations in ADLs when
chronically ill.
African-Americans are more likely than
Caucasians to have limitations in ADLs when
chronically ill.
Hispanics are more likely than African-
Americans and Caucasians to have limitations
in ADLs when chronically ill.
African-Americans are more likely than Caucasians to have
limitations in ADLs when chronically ill.
Gerontology nurses have the challenge to
educate the older population and their
families that a healthy old age can be
 achieved by:
Taking advantage of recommended preventive
health services and lifestyle changes.
Reducing their chances of disability with
vigorous exercises and balanced diet.
Becoming aware that cultural motivation is
the key to achieving a healthy old age.
A shift in paradigm as it relates to dietary
intake, rest, and yearly medical interventions.
Americans can improve their chances for a healthy old age by
simply taking advantage of recommended preventive health
services and by making healthy lifestyle changes.
The established goal of the National
Institute on Aging is to:
Provide appropriate healthcare to the
chronically ill, so as to lengthen their years.
Decrease the significant burden of care placed
on gerontology nurses and other healthcare
providers.
To "add life to years" by educating
professionals and supporting appropriate
research.
To help promote sophisticated levels of
interdisciplinary care and "fine-tune"
appropriate therapies.
The established goal of the National Institute on Aging is to "add
life to years" and to educate professionals and support research
that establishes specific, practical ways to reduce disability. The
National Institute on Aging does not provide direct healthcare
service to individuals. The agency's mission is to support and
conduct high-quality research, to train and develop highly skilled
research scientists, to develop and maintain state-of-the-art
resources, and to disseminate information to the public.
The gerontology nurse who is involved in
health promotion programs for older
persons living in the community and
diagnosed with Alzheimer's disease will
not focus on which of the following?
Assisting in the ability to make appropriate,
informed choices
Achieving optimal mental and physiological
health
Providing information and appropriate skills to
maintain lifestyle changes
Reducing genetic risk factors related to co-
morbidities of the older person
When cognitive capacity is impaired due to the diagnosis of
Alzheimer's disease or another irreversible neurogenerative
dementia, care and treatment decisions become even more
difficult. Treatment choices are not simple, because the burden of
treatment and the success of needed interventions requires a
skilled interdisciplinary team approach.
Which of the following classifications of
drugs would not directly cause delirium
through intoxication or withdrawal?
Anesthetics
Analgesics
Corticosteroids
Cardiotonics
Medications that can cause delirium through intoxication or
withdrawal include anesthetics, analgesics, anti-asthmatics,
anticonvulsants, antihypertensives, antimicrobials, corticosteroids,
gastrointestinal H2 blockers, muscle relaxants, hypnotics, and
psychotropic medications.
 Which of the following statements Healthcare providers can practice preventive ethics in order to
promote an environment where early identification of issues and
accurately describes modified aggressive
anticipation of possible dilemmas can serve to proactively avert
treatment for persons confined to nursing
potential areas of conflict. The knowledge of the values of the
homes? patient and family will allow the healthcare provider to anticipate
Modified aggressive treatment is usually where patient and family values might be in conflict.
appropriately delivered to older persons with
high functional ability.
Modified aggressive treatment is usually
appropriate for older persons with higher
degrees of frailty or multiple co-morbidities
Which of the following statements is accurate
who still have sufficient reserve capacity.
Modified aggressive treatment is appropriate
pertaining to the immune dysregulation theory?
for all older persons, and can be delivered
alone or in conjunction with aggressive or
modified care.
Modified aggressive treatment is delivered to
those with a life expectancy of six months or
less; patient's age is not a factor.

Modified aggressive treatment is usually appropriate for older he three characteristics that are unique to the immune system are
persons with higher degrees of frailty or multiple co-morbidities self-recognition, specificity, and memory. Antigens are a wide
who still have sufficient reserve capacity to respond to the range of substances that are identified as "non-self," and stimulate
demands of treatment. an immune response.

The three characteristics that are unique to the immune system

Because persons with end-stage dementia are self-recognition, specificity, and memory. Antigens are a wide
and physical frailty are in need of a range of substances that are identified as "non-self," and stimulate
Early identification of issues to help avert an immune response.
rational approach to care
potential areas of conflict. at the end of life,
preventive ethics to of
Having knowledge promote
the valuesa of
therapeutic
patient and
environment include: to healthcare.
family in relationship
Avoiding conflict resolution and The defense of natural immunity, or innate immunity, is not
communication skills with extended families. produced by the immune response that is present at birth.
Ongoing aggressive treatment of all disease Defenses of the innate immune system consist of a variety of
symptomatology to avert shortening of the physical barriers and biochemical and cellular defense mechanisms
elderly lifespan. to prevent the establishment of potential pathogens within the
body.

Which of the following factors affect
proper immune system function?
Age, exercise
Sunlight, nutrients in the diet
Diagnosis with co-morbidities
All of the above
Aging results in lifetime accumulative effects of environmental
exposures, such as sunlight, radiation, pesticides, and the amount
of illness and stress the aged persons have been exposed to.
The gerontology clinical nurse specialist is
teaching a group of new graduate nurses
how the body fights infection. When
discussing humoral immunity, the nurse
should explain that this protection is
mediated by which cell?
Basophil
Eosinophil
The B cell
The monocyte
The humoral immune response is initiated when an antigen binds
with antibody receptors on the surface of the mature B cell.
Which of the following statements are
accurate about the humoral immune
response and the cellular immune
response? (Select all that apply.)
The humoral immune response is directly
related to B cell surface receptors.
The cellular immune response is directly
related to the T cell surface receptors.
The humoral immune response is indirectly
related to the T cell surface receptors.
The cellular immune response is indirectly
related to the B cell surface receptors.
The humoral immune response is initiated when an antigen binds
with antibody receptors on the surface of the mature B cell. In the
cell-mediated immune response, T cells bind to the foreign antigen
in multiple areas on the surface of the cell.
A nurse is caring for a patient who is
deficient in T cells. The nurse would know
that T cell deficiency would result in which
of the following?
Hypersensitivity to allergens
Impaired cellular immunity
A decrease in the cell lifespan of granulocytes
A cellular inability to participate in
phagocytosis
T cells act directly with cellular targets, and are responsible for
cell-mediated immunity.
Which nursing intervention should be
attended to first for a client with a Type I
hypersensitivity reaction?
Administering naloxone (Narcan) stat
Obtaining blood sample for type and cross-
match
Initiating 0.9% NaCl intravenous solution
Establishing and maintaining a patent airway

Type I hypersensitivities are immediate, and can be life-
threatening. Manifestations include tightening of the throat,
shortness of breath, wheezing, tachycardia, and hypotension.
Which of the following clinical
manifestations of a patient suggests Type
IV hypersensitivity reaction?
Dermatitis from a latex allergy
Sudden shortness of breath
The appearance of hives
Swelling of the lips
Type IV hypersensitivity is also called delayed hypersensitivity.
Tissue is damaged as a result of a delayed T cell reaction to an
antigen. Examples of Type IV hypersensitivity include dermatitis
from a latex allergy, tuberculin reactions, and transplant
rejections.
Under which of the following
classifications of hypersensitivity would
systemic lupus erythematosus (SLE) and
rheumatoid arthritis be classified?
Type I hypersensitivity
Type II hypersensitivity
Type III hypersensitivity
Type IV hypersensitivity
Systemic lupus erythematosus is an example of type III
hypersensitivity reaction caused by auto-antibody production. The
antibodies are formed against nuclear DNA and RNA throughout
the body. Rheumatoid arthritis is another example of type III
hypersensitivity that affects older people. Antibodies form against
the person's own IgGs, and the resulting complex is identified as
foreign.
Which of the following classifications of
drugs are usually prescribed for patients
with rheumatoid arthritis?
Non-steroidal anti-inflammatory (NSAIDs)
Glucocorticoids
Mineralocorticoid
Answers 1 and 2
Drug therapy often consists of a combination of non-steroidal
anti-inflammatory drugs (NSAIDs), anti-rheumatic drugs, and
glucocorticoids.
Which of the following are unique
characteristics associated with human
immunodeficiency virus (HIV) infection in
the older person?
HIV infection in the older person most likely is
underdiagnosed and underreported.
Healthcare workers often do not take sexual
histories of older patients or recommend HIV
testing.
Symptoms of memory loss and weight loss
related to HIV often are treated as common
age-related health problems.
Older persons are contacting HIV infection
through heterosexual and homosexual
activities.
 (B) delirium
The older person's susceptibility to (C) functional psychosis
infections is related to: (Select all that
(D) mania
apply.)
A decline in responsiveness of the immune (E) organic delusional syndrome
system to harmful foreign invaders.
The febrile response that signals infections 2. The percentage of community-dwelling individuals older
sometimes being blunted in the older person.
Medications commonly taken that also
than 65 years who require
decrease the normal fever response. assistance with bathing, dressing, walking within their homes,
The body temperature in older people being using the toilet, or eating is
approximately 1ºF lower than normal, closest to
meaning a rise in temperature can go
unnoticed.
(A) 10%
(B) 30%
UCLA Geriatrics Knowledge Test (C) 50%
DIRECTIONS: Each of the questions or incomplete statements (D) 70%
below is followed by suggested
answers or completions. Select the ONE that is BEST in each
case.
1. One day after operative repair of a left intertrochanteric 3. A 78-year-old nursing home resident has mild dementia
fracture of the femur, an 83-yearold man is agitated, confused, associated with Alzheimer’s
and appears to be having visual hallucinations. He has disease. She is disoriented to time and place but knows family
accused the nursing staff of trying to kill him. He is a widower members and regular nurse
and has lived alone for 11 aides by name. This patient’s capacity to make decisions
years. He has been forgetful for the past year but can perform regarding her health care is best
all activities of daily living determined by
without assistance. On mental status examination he is easily (A) mental status test
distracted, perseverates, and (B) her ability to understand treatment options
does not respond coherently to questions about orientation and (C) probate court decision
memory. The most likely (D) psychiatric examination
diagnosis is
(A) Alzheimer’s disease 4. Which of the following instruments is most appropriate to
assess physical functional
abilities in a 75-year-old nursing home resident?
(A) Activities of Daily Living Scale
(B) Face/Hand Test
(C) Instrumental Activities of Daily Living Scale
(D) Zung Self-Rating Depression Scale
5. An 85-year-old man has a 4x7-cm Shea stage 3 pressure
ulcer over the sacrum. He has
been confined to bed since sustaining a hip fracture three
months ago and has lost 10 lb
during this time. Examination shows a foul-smelling wound,
necrotic tissue covering 50%
of the ulcer, and purulent drainage at the base. There is no
cellulitis. In addition to
surgical debridement, the most appropriate initial management
is
(A) topical application of neomycin/polymyxin/bacitracin
ointment
(B) topical application of sodium hypochlorite solution
(C) application of an adhesive polyurethane dressing
(D) myocutaneous flap
(E) none of the above
6. An 82-year-old nursing home resident has had a 7-lb weight
loss over the past two months.
She had a stroke seven years ago that resulted in aphasia. She
is bed bound and needs
assistance when eating. The staff reports that she often clamps
her teeth and refuses to eat.
Physical examination shows no abnormalities. The most
appropriate next step in
management is
(A) observation
(B) contact the family
(C) begin nasogastric tube feeding
(D) admit to the hospital
(E) perform percutaneous endoscopic gastrostomy
7. A 78-year-old woman has right hemiplegia and dysarthria
after a cerebral infarction in the
left pons three weeks ago. She has been fed through a
gastrostomy tube for two weeks
because of pneumonia of the left lower lobe, presumed to be
secondary to aspiration. She
is depressed and would like to begin oral feedings.
Examination shows a decreased gag
reflex and mild dysarthria. The most appropriate management
is
(A) continued tube feedings until gag reflex returns to normal
(B) encouragement to eat an appetizing diet
(C) ice chips orally and antidepressant therapy
(D) supervised oral feeding of pureed foods
(E) swallowing videofluoroscopy
8. The memory deficit that is most commonly caused by
depression is
(A) amnesia for traumatic events
(B) difficulty with free recall
(C) difficulty with multiple choice
(D) disorientation to person, place, and time
(E) symmetrical loss of multiple cognitive functions
9. Which of the following is best used for routine evaluation of Symptoms of obstruction, including hesitancy, straining, and
nutritional status in older intermittent urinary stream,
persons? have improved. He is otherwise healthy and takes no
(A) Delayed skin testing medications. Urinalysis shows
(B) Serial weight measurements normal findings. After voiding 220 mL without straining,
(C) Serum albumin level measurement postvoid residual volume is 40
(D) Serum transferrin level measurement mL. The most appropriate next step in management is
(E) Total lymphocyte count (A) oxybutynin 2.5 mg three times daily for a two-week trial
(B) terazosin 0.5 mg twice daily for a two-week trial
10. The most common community-acquired infection that (C) cystoscopy
results in hospitalization in older (D) cystometrography
persons is
(A) infected pressure ulcers 13. An 82-year-old woman with Alzheimer’s disease sustains a
(B) influenza displaced fracture of the
(C) pneumonia femoral neck in a fall. She resides in a nursing home because
(D) tuberculosis of her cognitive deficits.
(E) urosepsis Prior to the injury, she was independent in ambulation, feeding,
toileting, and transferring,
11. Approximately what percentage of the cost of long-term but needed cueing to bathe and dress. Her score on the Mini-
care is paid for directly by elderly Mental State Examination is
persons or their families? 11/30. The most appropriate management of the fracture is
(A) 30% (A) use of crutches and limited mobility
(B) 50% (B) traction and bed rest
(C) 70% (C) open reduction and internal fixation
(D) 90% (D) prosthetic replacement of the femoral head

12. An 82-year-old man has worsening of urge incontinence, 14. A 70-year-old man with diabetes mellitus and emphysema
urinary frequency, and nocturia comes to your office in
three months after transurethral resection of the prostate for December for influenza vaccination. You have cared for this
benign prostatic hyperplasia. patient for the past six
months and no additional medical records are available. He (E) Verification of need by two independent physicians
reports that prior to your care,
his last visit to a physician was 10 years ago. He also reports 17. What percentage of persons who are age 65 years and
that he received a tetanus older will require nursing home care
“shot” in the emergency department four years ago because of at some time during their life?
a laceration. Which of the (A) 5%
following is the most appropriate schedule for immunization? (B) 25%
(A) Influenza vaccine only at this visit (C) 45%
(B) Influenza and pneumococcal vaccines at this visit (D) 65%
(C) Influenza vaccine at this visit and pneumococcal vaccine (E) 85%
in eight weeks
(D) Pneumococcal vaccine at this visit and influenza vaccine 18. A 79-year-old woman has had confusion since admission to
in eight weeks the hospital for pneumonia one
week ago. Her prior cognitive status is unknown; she appeared
15. A 76-year-old woman has pain in the right hip and is malnourished and unkempt
unable to walk without support three on admission. She has responded well to antibiotic therapy and
days after a fall. Passive motion of the right hip produces pain is currently afebrile. She
in the groin. Plain is pleasant and attentive to questions. Mental status
radiographs of the pelvis show no abnormalities. The most examination reveals disorientation,
likely cause of her symptoms is memory impairment, and language abnormalities; she is unable
(A) muscle strain to draw the face of a clock.
(B) occult fracture of the hip The remainder of the physical and neurologic examination
(C) osteoarthrosis shows no abnormalities. The
(D) referred pain from the spine most likely diagnosis is
(A) age-associated memory loss
16. Which of the following is required for eligibility for the (B) delirium
Medicare Hospice Benefit? (C) dementia
(A) Diagnosis of a terminal malignancy (D) depression
(B) Enrollment in Medicare Part A (E) paraphrenia
(C) Forfeiture of all Veterans’ benefits
(D) Supplemental insurance policy
19. A 68-year-old man has a moderate left hemiparesis and (E) noncompliance
severe neglect six days after a right
hemispheric stroke. He appears to be in denial about his 21. An otherwise healthy 73-year-old man with Parkinson’s
degree of impairment and states disease has difficulty walking. He
that he hopes to be discharged from the acute hospital to his has had many changes in his antiparkinsonian medication and
home where he has lived alone feels that the present
for the past 10 years. During physical therapy sessions, he is regimen is the best he has ever had. Analysis of gait reveals
apathetic and tires easily after very slow step initiation,
30 minutes. Further evaluation shows no abnormalities. decreased stride length with shuffling, and moderate
Which of the following is the retropulsion. Which of the following
most appropriate site for rehabilitation? devices is most likely to improve his gait?
(A) Home-care program (A) A straight cane
(B) Outpatient physical therapy program (B) A four-prong quad cane
(C) Acute inpatient rehabilitation program (C) A walker with arm troughs attached
(D) Nursing home (D) A pick-up four-legged walker
(E) Inpatient geropsychiatric unit (E) A front-wheeled walker
Items 22-23
20. An 84-year-old man is fitted for and trained in the use of a For each patient, select the most appropriate management (A-
hearing aid. Three months later, L).
he reports that he has stopped using the hearing aid because, (A) Pelvic muscle exercises
although he can hear better, he (B) Prompted voiding
still cannot understand what people are saying. He states that (C) Biofeedback
background noise is also a (D) Urodynamic assessment
problem. He has hypertension but is otherwise healthy. His (E) Oxybutynin 2.5 mg three times daily
score on the Mini-Mental (F) Phenylpropanolamine 75 mg twice daily
State Examination is 30/30. The most likely cause of the (G) Vaginal estrogen daily
hearing difficulty is (H) Terazosin 0.5 mg twice daily
(A) central auditory processing disorder (I) Bethanechol 10 mg three times daily
(B) early signs of dementia (J) Bladder neck suspension
(C) improper fit of the hearing aid (K) Intermittent catheterization
(D) Meniere’s disease (L) Chronic indwelling catheterization
22. An 82-year-old woman is admitted to a nursing home two 3. The progression of intermittent claudication is measured by
weeks after operative repair of a the:
hip fracture. She has an indwelling catheter for recurring 1. distance walked before leg pain starts.
postoperative urinary retention. 2. pedal edema after dangling the legs for 20 minutes.
3. peripheral pulses in the affected leg.
23. An 89-year-old woman with Alzheimer’s disease, mild 4. skin temperature and color of the feet.
congestive heart failure, and Correct Response: 1
glaucoma has urinary incontinence several times daily,
occurring both day and night and 4. An early sign of alcohol withdrawal is:
without residual urine. She is wheelchair-bound and resides in 1. auditory hallucinations.
a nursing home. 2. decreased blood pressure.
3. depression.
4. diaphoresis.
Correct Response: 4
1. For an individual with age-related hearing loss, which sound 5. A stage III pressure ulcer is characterized by:
is most difficult to hear? 1. blisters, abrasions, or shallow craters.
1. A recording of a march played softly 2. deep craters with or without undermining and full-thickness
2. A young child talking in a cafeteria line skin loss involving
3. Hammering during construction of a house next door subcutaneous tissue.
4. The voice of a man speaking in an elevator 3. full-thickness skin loss with tissue necrosis or damage to
Correct Response: 2 muscle or bone.
4. partial-thickness skin loss involving the dermis or epidermis.
2. Pain of gastrointestinal origin is best differentiated from pain Correct Response: 2
of cardiac origin by the
presence of: 6. The primary risk factor for the development of pressure
1. chest pain lasting longer than five minutes. ulcers in older adult patients is:
2. chest pain of rapid onset. 1. immobility.
3. left flank pain. 2. impaired circulation.
4. substernal chest discomfort. 3. incontinence.
Correct Response: 4 4. malnutrition.
Correct Response: 1 4. oxygen therapy at 3 L/min as needed and deep-breathing
exercises for
7. An 80-year-old resident of a retirement center states that relaxation.
something is wrong with the Correct Response: 1
lighting in the room because colored rings appear around the
light bulbs. The resident 10. A 65-year-old man with a 45-year history of smoking
most likely has: complains of a change in his
1. cataracts. cough pattern, a nonproductive cough, and an ache in his chest.
2. delusions. The man's chest x-ray
3. glaucoma. reveals an infiltrate. The gerontological nurse suspects:
4. increased intracranial pressure. 1. a lung tumor.
Correct Response: 3 2. chronic obstructive pulmonary disease.
3. pulmonary edema.
8. The most common cause of chronic pain in older adults is: 4. tuberculosis.
1. arthritis. Correct Response: 1
2. fractures. 11. Which symptom in older adults is most indicative of a
3. headaches. urinary tract infection?
4. neuropathy. 1. Confusion
Correct Response: 1 2. Dysuria
3. Fever
9. A 72-year-old man with asthma, chronic obstructive 4. Frequency
pulmonary disease, and chronic Correct Response: 1
anxiety is admitted to a nursing home. Care plan objectives for
this man include: 12. Which is a risk factor for vaginitis in older adult women?
1. adherence to his medication regimen, inhalation therapy, and 1. Anticoagulation therapy
instruction about 2. Increased sexual activity
methods of conserving energy. 3. Poor nutrition
2. an exercise program to increase the vital capacity of his 4. Prolonged antibiotic therapy
lungs. Correct Response: 4
3. instruction in respiratory exercises with emphasis on forced
inhalation.
13. Which condition might be indicated by an increase in Correct Response: 1
hemoglobin values? 1. Dehydration
2. Infection 17. Heat stroke is a serious form of hyperthermia that is
3. Malnutrition characterized by:
4. Opiate use 1. absence of sweating.
Correct Response: 1 2. decrease in body temperature.
3. increase in sweating.
14. An 83-year-old female patient underwent a total hip 4. nausea and vomiting.
replacement three days ago. She Correct Response: 1
should not cross her legs because:
1. abduction of the hip can cause dislocation of the prosthesis. 18. A gerontological nurse is teaching dressing techniques to a
2. adduction of the hip can cause dislocation of the prosthesis. patient with right hemiplegia
3. blood clots often result from pressure on arteries in the legs. and a severe speech impairment. An appropriate first step in
4. contracture can be prevented by avoiding acute flexion of the nurse's teaching would
the hip. be to:
Correct Response: 2 1. ask the patient to put on a shirt.
2. demonstrate the proper way to put on a shirt.
15. A 76-year-old patient with osteoarthritis complains of pain, 3. explain the difficulties in putting on a shirt.
stiffness, and deformities of 4. give verbal instructions on dressing procedures.
the fingers. The gerontological nurse recommends: Correct Response: 2
1. cold packs.
2. exercise. 19. Older adults with Parkinson disease exhibit:
3. meditation therapy. 1. confusion and depression.
4. vitamin therapy. 2. dementia and hyperkinesia.
Correct Response: 2 3. rigidity and tremor at rest.
4. weakness and tremor with movement.
16. A factor that contributes to hypothermia in older adults is: Correct Response: 3
1. decreased activity.
2. decreased vulnerability to cold. 20. To prevent injury, a gerontological nurse advises an older
3. increased perception of cold. adult who is taking tricyclic
4. increased subcutaneous fat. antidepressants to:
1. eat a diet high in roughage. 24. A 78-year-old patient calls a telephone triage nurse and
2. get an additional night light. reports several falls after taking
3. provide lubrication for the oral mucosa. over-the-counter medication for a recent cold. Which
4. stand up slowly from sitting or lying positions. medication contributed to the falls?
Correct Response: 4 1. Diphenhydramine (Benadryl)
2. Ferrous sulfate
21. Persons who are taking anticholinergic drugs are at high 3. Guaifenesin (Robitussin)
risk for: 4. Loratadine (Claritin)
1. cardiac arrhythmias. Correct Response: 1
2. dry mouth.
3. orthostatic hypotension. 25. Older adults who take the herbal supplement cascara
4. slurred speech. sagrada are monitored for the
Correct Response: 2 presence of:
1. fever.
2. hypokalemia.
22. Age-related changes in which two organs most affect an 3. jaundice.
older adult's reaction to 4. vertigo.
medication? Correct Response: 2
1. Heart and lungs
2. Intestines and spleen 26. A nursing home conducts a survey to evaluate nursing care.
3. Liver and kidneys However, some residents
4. Pancreas and gall bladder did not express their concerns due to fear of reprisal by the
Correct Response: 3 staff. Which aspect of the
evaluation is most affected?
23. Sildenafil citrate (Viagra) is hazardous for patients with: 1. Generalizability
1. a history of coronary artery bypass graft. 2. Reliability
2. a history of shingles. 3. Statistical significance
3. heart failure and borderline hypotension. 4. Validity
4. Paget disease and hypertension. Correct Response: 4
Correct Response: 3
27. A common side effect of angiotensin-converting enzyme
inhibitors that frequently results
in discontinuation of therapy is: 1. a dry, persistent cough.
2. exacerbation of heart failure.
3. sedation.
4. urinary incontinence.
Correct Response: 1
28. A patient with Stage 2 Alzheimer disease visits the mental
health clinic. During the
interview, the patient becomes hostile and refuses to answer
further questions. The
gerontological nurse's best action is to:
1. ask if the questions upset the patient in any way.
2. discontinue the interview.
3. explain that the information is needed to plan the patient's
care.
4. ignore the patient's reaction and proceed.
Correct Response: 2
29. A gerontological nurse at a nursing home conducts a
reminiscence therapy group for
residents with confusion. A member of the group stands up and
says, “I just heard my
cow. I have to go and milk her now.” The nurse's most
therapeutic response is:
1. “All right, you may leave the group now.”
2. “Please tell us about your cow.”
3. “That wasn't a cow; maybe you heard a vacuum cleaner.”
4. “You live here at the nursing home now, not on the farm.”
Correct Response: 2
30. Reminiscence therapy promotes an older adult's sense of
security by:
1. increasing socialization skills.
2. meshing the past with the future.
3. providing praise and recognition.
4. reviewing comforting memories.
Correct Response: 4
31. A physician has just informed an older adult patient that
test results indicate that the
patient has cancer and will require extensive surgery. The
patient says, “I know the
tests are wrong. I feel fine.” The gerontological nurse's most
appropriate response is to:
1. acknowledge that the patient looks healthy and encourage
seeking a second
opinion.
2. advise the patient to join a support group.
3. convey availability to talk to the patient. 4. tell the patient
that the tests are reliable and accurate.
Correct Response: 3
32. A 75-year-old patient who sustained a stroke has residual
left-sided weakness. From
the first day of hospitalization, the patient has been combative
and demanding, and has
refused to swallow any medication. The most constructive
nursing action is to:
1. continue to attempt to follow the physician's orders.
2. determine the patient's premorbid personality.
3. restrain the patient and request a change in the route of The patient does not use alcohol, caffeine, or any medications
medication. other than
4. wait for the patient to become more cooperative. acetaminophen for arthritis pain. The patient goes to bed at
Correct Response: 2 11:00 pm, falls asleep in 15
minutes, awakens several times during the night, and promptly
33. A healthy 80-year-old female patient complains that her goes back to sleep. The
skin feels dry and sometimes patient feels refreshed in the morning and works five days a
itchy. The gerontological nurse advises her to: week as a volunteer. The
1. avoid scratching since breaks in the skin increase the risk of gerontological nurse's most appropriate response is to:
infection. 1. recommend that the patient eliminate fluid intake after 6:00
2. drink more liquids and take showers instead of baths. pm.
3. take fewer baths, use soap sparingly, and apply skin cream 2. recommend that the patient go to bed one hour earlier. 3.
afterward. suggest that the patient enroll in a sleep study.
4. wear cotton clothing and try a different brand of soap. 4. tell the patient that the sleeping pattern is a normal age-
Correct Response: 3 related change.
34. A 90-year-old patient with multiple medical problems is Correct Response: 4
admitted to the hospital's 36. Which signs are characteristic of deep vein thrombosis?
geriatric care unit. The nursing assessment reveals lethargy, 1. A cool, non-tender limb
poor capillary perfusion, 2. Limb numbness with diaphoresis
and urinary incontinence. These findings alert the 3. Rapid onset of unilateral leg swelling with dependent edema
gerontological nurse to the potential 4. Vertigo with an abrupt onset of blurred vision
for: Correct Response: 3
1. aspiration.
2. contractures. 37. Unusual symptoms of pneumonia often found in long-term
3. dehydration. care residents include:
4. skin breakdown. 1. anorexia and new behavioral problems.
Correct Response: 4 2. headache and difficulty breathing.
3. muscle aches and fever.
35. An 80-year-old patient complains of sleeping less despite 4. nonproductive cough and chest pain.
spending more time in bed. Correct Response: 1
38. Which symptom is exhibited first by an older adult with a 4. restore the patient's fluid and electrolyte balance.
urinary tract infection? Correct Response: 4
1. Anorexia
2. Confusion 42. The adult children of an aging couple ask a gerontological
3. Fever nurse about alternative
4. Restlessness therapies or nontraditional services to improve their parents'
Correct Response: 2 health. The nurse's most
appropriate response is to:
39. Which assessment tool measures economic resources, 1. discuss the benefits, risks, and limitations of various
mental health, and activities of therapies.
daily living? 2. distinguish between folk and traditional medicine.
1. Lawton's Physical Self-Maintenance Scale 3. give a firm warning about alternative therapies.
2. Older Americans Resources and Services Assessment 4. recommend a reputable holistic health therapist.
3. Problem Oriented Medical Record Correct Response: 1
4. Short Portable Mental Status Questionnaire
Correct Response: 2 43. A 73-year-old patient is admitted to a rehabilitation facility
40. All care plans for older adult patients include: after sustaining a mild stroke.
1. a bowel and bladder program. After three nights in the facility, the patient begins to sleep
2. a fall prevention program. 3. discharge planning. only four to five hours a night
4. reminiscence therapy. and to awaken frequently during the night. The patient then
Correct Response: 3 complains of not feeling
rested and begins to nap during the day. Which is the most
41. An older adult patient, who is recovering from surgery, has appropriate nursing action?
a sodium level of 128 mEq/L 1. Completing an assessment of the patient's sleep-wake cycle
and is confused. The physician diagnoses syndrome of to determine
inappropriate secretion of necessary interventions
antidiuretic hormone. The gerontological nurse's primary goal 2. Doing nothing since this type of sleep pattern is associated
for this patient is to: with normal aging
1. decrease edema by restricting free water intake. 3. Inquiring if the patient takes a medication at bedtime and
2. prevent complications of hyponatremia. requesting that the
3. reorient the patient to his or her surroundings. physician order it
4. Moving the patient further away from the nurse's station to 2. move him as quickly as possible so that he does not have
minimize disturbances time to think.
Correct Response: 1 3. restrict family visits for the first two weeks to give him time
to adjust.
44. A 68-year-old man calls his daughter every night to talk 4. suggest that he bring his favorite things from home to make
about his beloved wife who died his room seem
four weeks ago. During the day, he is sad and goes out familiar.
frequently to get away from the Correct Response: 4
empty house. The man's most probable state is:
1. depression. 2. mourning. 47. An 80-year-old patient is in the terminal stage of Alzheimer
3. neurosis. disease. The treatment team
4. prolonged grief. meets with the patient's who are angry and complain about a
Correct Response: 2 recent incident in which
their parent's dentures were misplaced. The team members
45. The main reason that older adults with a chronic illness realize that:
tolerate functional impairments 1. anger at staff is a symptom of grief and needs to be
is that they: addressed.
1. are afraid to seek medical advice for fear of what they may 2. anxiety about the meeting may have interfered with the
find. children's affect.
2. associate their symptoms with aging rather than an illness. 3. material items are the focus for the children at this time.
3. believe in home remedies and parental traditions. 4. the focus of control should shift to the parent.
4. relate their symptoms to conditions that resolved in the past Correct Response: 1
without treatment.
Correct Response: 2 48. When relocating from a family home to a continuing care
community, the most crucial
46. An 87-year-old man, who has been living independently, is factor in an older person's adjustment is his or her:
entering a nursing home. To 1. level of economic independence.
help him adjust, the most effective action is to: 2. perceived control of the move.
1. involve him in as many activities as possible so he can meet 3. physical proximity to remaining family.
other residents. 4. risk-taking ability.
Correct Response: 2
 2. changing the topic when a patient talks about his or her
49. A 78-year-old male resident at a long-term care facility, morbid past.
who is a former business 3. encouraging reminiscence, oral histories, and storytelling.
executive, has been smoking and extinguishing cigarettes in a 4. helping the older adult explore how spiritual involvement
paper cup in areas assists with stress relief.
where smoking is prohibited. He has been informed repeatedly Correct Response: 3
of the designated
smoking areas. The resident's behavior indicates an attempt to: 52. The holiday season is approaching and a woman is
1. express self-transcendence. admitted to a psychiatric unit. She
2. maintain autonomy by exercising control. reports that her husband of 45 years passed away four weeks
3. maintain his previous professional role. ago. She frequently cries,
4. react against the facility's ageism. eats poorly, periodically complains of back and stomach aches,
Correct Response: 2 and has begun isolating
herself. What type of grief is this woman exhibiting?
50. A gerontological nurse is caring for an older adult who has 1. Acute
been confined to home for 2. Anticipatory
the last 10 weeks due to illness. The patient is anxious, has 3. Disenfranchising
multiple somatic 4. Dysfunctional
complaints, and has become unable to follow instructions. The Correct Response: 1
nurse knows that this
phenomenon commonly occurs with: 53. A 92-year old patient, who recently underwent a below-the-
1. environmental overload. knee leg amputation, is
2. protective isolation. resisting attempts at rehabilitation. The most likely reason for
3. selective inattention. the resistance is that the
4. sensory deprivation. patient:
Correct Response: 4 1. has goals that differ from the rehabilitation care plan.
2. has too many disabilities to realistically plan for
51. The gerontological nurse facilitates the benefits of life rehabilitation.
review by: 3. is too old to undergo rehabilitation.
1. assisting the older adult to accept death as the inevitable last 4. requires a psychiatrist's assistance to deal with the loss.
stage. Correct Response: 1
 1. Becoming defensive when questions are asked
54. When the gerontological nurse in a clinic asks a 70-year- 2. Complaining about care delivered by hospital staff
old man about his sexual 3. Giving an illogical account of her mother's fall
activity, he begins to cry and says, “I feel so bad for my wife; 4. Refusing to leave her mother alone to answer questions
she is only 60, and I can't Correct Response: 4
seem to satisfy her as often as I used to.” Which is the nurse's
most appropriate 56. In teaching an older adult client, the gerontological nurse's
response? most appropriate initial
1. “At your age, sexual activity diminishes because of changes strategy is to:
in your circulation. I 1. assess the client and individualize the teaching methods.
will explain this to your wife.” 2. set a slow learning pace and begin teaching simple concepts.
2. “Certain body functions, such as erections, slow down with 3. teach slowly and use repetition.
age. Could you tell 4. use demonstration and provide ample opportunity for
me more about your sexual relations? For instance, how often practice.
do you have Correct Response: 1
intercourse?”
3. “Your problem is probably an emotional one. If you could 57. In preparing a presentation for older adults, a
relax, you would be as gerontological nurse keeps in mind that:
sexually active as you were 10 years ago.” 1. older adults are unlikely to participate in educational
4. “Your problem is probably due to a decrease in your sexual programs due to lack of
hormones. This interest.
occurs naturally as people age.” 2. older adult learners are heterogeneous due to diverse
Correct Response: 2 educational experiences
and learning strategies.
55. An alert and oriented 82-year-old woman, who lives with 3. the ability to acquire knowledge from a verbal presentation
her daughter, has been decreases with age
admitted to the hospital with bruises about the face and head. more than the ability to acquire knowledge through reasoning.
The daughter reports that 4. the age-related decline in intellectual performance creates
her mother fell. Which behavior by the daughter raises the obstacles for acquiring
greatest suspicion of elder new information.
abuse? Correct Response: 2
 4. is stimulating so as to challenge thought.
58. Members of a family are caring for their father at home. Correct Response: 2
Which statement by a family
member indicates a need for teaching and caregiver 61. In assessing the lighting for a patient with glaucoma, the
instruction? gerontological nurse knows
1. “Dad has gotten lazy about his bathroom habits. He blames that:
his arthritis 1. ceiling lights are best.
medication for his toileting accidents.” 2. drapes should be left open during the daylight hours.
2. “Dad's room is close to the bathroom and we keep a light on 3. higher levels of light are needed.
for him at night.” 4. lower levels of light are needed.
3. “It's inconvenient, but we stop other activities to remind Dad Correct Response: 4
to go to the 62. A 63-year-old patient is returning home after being
bathroom on a regular schedule.” hospitalized for injuries received
4. “We try to avoid coffee and tea at night, but Dad really likes during a robbery and home invasion. Although neighborhood
a cup of coffee for robberies are rampant, the
breakfast.” patient has lived in the same house for 50 years and does not
Correct Response: 1 want to move. The
patient receives a monthly social security check. The
59. When hospital quality assurance indicators are assigned, gerontological nurse's most
the nursing staff strives to: appropriate step is to:
1. avoid emphasizing performance deficits. 1. advise the patient to arrange for someone to visit regularly or
2. decrease patient falls. move into the
3. focus on achieving 100% compliance. home.
4. identify high-risk, high-volume, or problem-prone areas. 2. advise the patient to have the social security check deposited
Correct Response: 4 directly to the bank
and to get a dog.
60. The most appropriate environment for a person with 3. assume that the patient is incompetent and initiate
chronic dementia is one that: commitment proceedings.
1. changes often to decrease boredom. 4. take no action since the patient has a right to autonomy.
2. contains familiar objects. Correct Response: 2
3. is limited in color and sound.
63. A gerontological nurse in a daycare program for older 2. Hip
adults observes that the 3. Shoulder
participants have long toenails, corns, calluses, and other 4. Vertebral
problems indicating a need Correct Response: 2
for better foot care. What is the nurse's best action?
1. Developing an educational program on foot health and 66. The primary reason for establishing quality improvement
arranging for podiatry committees at long-term care
services at the site facilities is to:
2. Establishing a regular foot care plan whereby the 1. facilitate staff participation.
participants' toenails would be 2. initiate changes based on interdisciplinary exchange.
cut and corns and calluses shaved 3. monitor and record incidents, accidents, and injuries.
3. Instructing competent family members in the proper 4. provide quality care based on measurable data.
methods of cutting toenails Correct Response: 4
and using commercial foot care products.
4. Recommending that the participants soak their feet for 10 67. An accrediting body evaluates a nursing home by
minutes before cutting monitoring the number of residents
their toenails using safe toenail clippers who developed pressure ulcers and urinary tract infections.
Correct Response: 1 What type of audit is being conducted?
1. Outcomes
64. The occurrence of tuberculosis in the older adult is 2. Process
significantly increased among 3. Prospective
individuals who 4. Structure
1. are physically inactive. Correct Response: 1
2. are cigarette smokers.
3. have received the Bacile Calmette Guérin (BCG) vaccine. 68. A gerontological nurse is creating a staff development
4. reside in institutions. program for a unit. To assess the
Correct Response: 4 staff's learning needs, the nurse's best approach is to ask staff
members:
65. Which type of fracture has the highest morbidity and 1. “How do you want to learn new material?”
mortality in the older adult? 2. “What do you need to know to do your job better?”
1. Ankle 3. “What do you think others need to learn?”
4. “What do you think others want you to learn?”
Correct Response: 2
69. A comprehensive staff development program in a long-
term care facility is based on the:
1. availability of educational resources.
2. nursing director's perceptions of staff learning needs.
3. philosophy, goals, and objectives of the organization.
4. recommendations of the ombudsman.
Correct Response: 3
70. A gerontological charge nurse delegates the administration
of a nasogastric tube
feeding to a licensed practical nurse (LPN). Which statement
about this situation is most
accurate?
1. The charge nurse is responsible for delegated care.
2. The charge nurse should implement the care and not
delegate the task.
3. The LPN is accountable for his or her own actions.
4. The LPN should respectfully refuse to initiate this care.
Correct Response: 1
71. Which profession first developed standards of
gerontological care and provided a
certification mechanism to ensure expertise?
1. Medicine
2. Nursing
3. Physical therapy
4. Social work
Correct Response: 2
72. The gerontological nurses in a teaching nursing home are
informed of a research
project to obtain voiding cystometrograms on all residents. The
gerontological nurses'
responsibility is to ensure that the:
1. non-English speaking residents receive a complete
explanation of the study in
their native languages.
2. nursing home administration know that the nurses do not
support such invasive
studies on the residents.
3. research team is well staffed so that the nursing home staff
can provide care as usual.
4. residents will be properly medicated in the examining room
where the tests will be conducted.
Correct Response: 1
73. Which is an accurate statement about Medicare?
1. Medicare is a health insurance program with carefully
described benefits that may restrict the length of hospital stays.
2. Medicare patients can expect to receive routine household
and attendant care under Part A of their Medicare insurance.
3. Medicare pays for the majority of nursing home care for
persons who are 65 years of age or older.
4. Persons covered by Medicare must pay once-in-a-lifetime
deductibles on both the physician and hospital portions of the
program.
Correct Response: 1
74. Nursing facilities that receive federal funds must complete
for all residents a:
1. minimum data set and care plan within seven days. The gerontology nurse practitioner should
2. resident assessment instrument and care plan on admission. rule out (R/O) which symptom before the
3. resident assessment instrument and care plan within 14 days. diagnosis of dementia is made?
4. resident assessment instrument within 14 days and a care History of seizures (convulsions)
plan within 21 days. History of head injury
Correct Response: 4 History of schizophrenia

History of delirium
75. The primary function of an ombudsman is to:
1. act as a clearinghouse for complaints and problems.
Because cognition impairment caused by delirium might be
2. initiate complaints about the facility's operations. reversible, delirium must be ruled out when diagnosing dementia.
3. question the facility administrator and the director of
nursing.
4. welcome and interview patients and their families. The definitive medical diagnosis of AD is
Correct Response: 1 confirmed by:
Histopathological findings.

History and physical examination.

Neuropsychological testing.

Combing estimates of genetic and

environmental risk factors.

The definitive diagnosis of AD is provided only after

histopathological confirmation at autopsy. However, clinical
diagnosis can be made from history, physical examination, and
neuropsychological testing.

Which of the following statements is

The majority of cases of Alzheimer's disease (AD) result from accurate pertaining to frontotemporal
complex interactions between genetic and environmental factors. dementia? Frontotemporal dementia:
Studies have shown that the major risk factor for developing AD is (Select all that apply.)
the Σ4 allele of the apolipoprotein (APOE) on chromosome 19. Includes Lewy bodies, and is diagnosed on the
basis of personality changes.
Is an abrupt-onset dementia with abnormal
reflexes and emotional ability.
 Includes Pick's disease, and is diagnosed on
the basis of personality changes and the
presence frontal brain atrophy.
Includes Lewy bodies, Pick's inside nerve
cells, and behavioral disinhibition.
Frontotemporal dementia, which includes Pick's disease, is
diagnosed on the basis of personality changes and the presence of
frontal brain atrophy.
Parkinsonian disease (PD) is referred to as
an extrapyramidal syndrome because it
manifests which of the following clinical
symptoms?
Tremor and bradykinesia
Diarrhea and sweating
Constipation and hypotension
Somnolence and poor gait
Parkinsonian disease (PD) has variable combinations of signs and
symptoms that include tremor, rigidity, bradykinesia, and
disturbances in gait.
Which of the following drugs would be
ordered for persons with Parkinsonian
disease?
Carbidopa/Levodopa (Sinemet)
Carbenicillin Indanyl sodium (Geocillin)
Carboplatin (Paraplatin)
Carisoprodol (Rela)
The pathology of PD is related to the loss of dopaminergic cells
situated deep in the midbrain in the substantia nigra. Dopamine is
necessary for neurotransmission of nerve terminals, which is
involved in the initiation of movement. Levodopa is the metabolic
precursor of dopamine that provides symptomatic relief of some of
PD symptoms, especially bradykinesia. Levodopa is combined with
Carbidopa, which is a peripheral dopa-carboxylase inhibitor.
Nurses who administer Sinemet as
prescribed for the elderly should
incorporate timing of the administration of
Sinemet into the patient's care plan and:
Give Sinemet 30 minutes after meals.
Give Sinemet 30 minutes before meals.
Give Sinemet one hour before meals.
Give Sinemet with meals, followed by a glass
of water.
Sinemet should be taken on an empty stomach. The nurse should
incorporate timing of the administration of Sinemet into the
patient's plan of care. Both the patient and caregiver should be
taught that Sinemet should be taken one hour before or two hours
after a meal.
The pathology of a stroke typically is not
caused by which of the following?
Hemorrhage into the brain
An embolus or thrombus that occludes an
 artery
Rupture of an extracerebral artery, causing
subarachnoid hemorrhage
Damage to the cerebrum and myelin sheath
The pathology of a stroke typically is caused by hemorrhage into
the brain, an embolus or thrombus that occludes an artery, or
rupture of an extracerebral artery, causing subarachnoid
hemorrhage.
Measuring the patient's height and weight
accurately.
There are several nursing interventions when caring for a patient
with a history of seizures. It is the nurse's responsibility to obtain
an accurate patient history, including age of seizure onset and
frequency of attacks. It is important for the nurse to be aware of
the medication dose, because many patients are given a starting
dose, which might need to be titrated.

The most important responsibility of the

Which prescription most likely would be
nurse when a patient has a seizure is to:
ordered if not contraindicated for acute Maintain the head-tilt-chin lift method.
ischemic stroke?
Packed red blood cells (PRBC), followed by Provide oxygen immediately.
furosemide (Lasix)
Prevent injury of the patient.
25% albumin followed by 0.9% sodium
chloride Prevent status epilepticus.
Recombinant-tissue plasminogen activator (rt-
PA)
If a patient has a seizure, the most important responsibility of the
Heparin infusion alternating with coumadin
nurse is to prevent injury to the patient. Oxygen should always be
(Warfarin)
available, and the head-tilt-chin method can be used to obtain an
If thrombolytic therapy is not contraindicated, then recombinant airway.
tissue plasminogen activator (rt-PA) often will be administered
within three hours to treat the acute ischemic stroke. However, not
all patients treated with rt-PA therapy will have positive outcomes.

Nursing interventions for persons with

history of seizure would include: (Select
all that apply.)
Patient-family education in regards to
Obtaining an accurate patient history.
seizures would include: (Select all
Knowledge of the frequency of attacks. that apply.)
Providing patient and family with
Being aware of the medication dosage and
audiovisual aids for ongoing review.
frequency.
Teaching how to identify and avoid
 precipitating factors for seizures.
Stressing the need to take medication as
prescribed.
Teaching what to do in the event a
seizure occurs.
Small, frequent feedings requires less release of hydrochloric acid.
Remaining in an upright position for 30 minutes after meals
Which of the prevents reflux into the esophagus.
following are
aged-related
changes that Decline in
sense of Persons with GERD should be referred to a primary care provider
affect for a thorough cardiac evaluation to rule out cardiac disease. The
taste and
gastrointestinal smell, most frequently used diagnostic test is barium swallow. Upper
function? decrease in endoscopy is the best method to assess mucosal injury. Acid
(Select all that salivary perfusion tests usually are not necessary, and require the
apply.) secretion placement of an esophageal probe above the esophageal sphincter
Diminished to collect esophageal contents.
capacity of
the gastric
mucosa to
resist such Bed-bound patients should not be fed in the semi-reclined position
factors as or fed thin liquids that might quickly drain into the esophagus
Helicobacter before the swallow reflex is triggered. A heavy caseload of clients
pylori might cause healthcare providers to rush-feed patients, resulting
Achlorhydria in reflux of nutrients and gastric acid.
or insufficient
hydrochloric
acid in the
Stroke, especially in the midbrain and anterior cortical areas, is the
stomach
most common cause of dysphagia in the older person. Parkinson's
Decreases in
disease and Alzheimer's disease can cause dysphagia by inhibiting
intestinal
movements of the tongue, pharynx, or upper esophagus. Crohn's
absorption,
and ulcerative colitis affect the G.I. mucosa and submucosa, and
motility, and
do not usually cause esophageal reflux or aspiration.
blood flow

Preparation of the videofluoroscope radiographic evaluation

includes drinking of a radio opaque solution, which is a chalk
mixture. The chalk mixture is constipating, and could cause fecal
impaction.
Which of the following statements are
accurate as they relate to medications
used to manage GERD? (Select all that
apply.)
Magnesium-containing antacids can cause
diarrhea.
Aluminum-containing antacids can cause
constipation.
Cimetidine (Tagamet HB) causes osteomalacia
and hypophosphatemia.
Misoprostol's (Cytotec) major side effect is
G.I. bleeding.
Magnesium-containing antacids can cause diarrhea, and
should be used with caution in older persons with renal
dysfunction. Aluminum-containing antacids can cause constipation,
osteomalacia, and hypophosphatemia. Cimetidine has the greatest
chance for adverse reactions, including erectile dysfunction,
Gynecomastia, and confusion. Misoprostol's major side effects are
diarrhea and abdominal pain.
The surgical procedure of choice for older
patients with GERD and Barrett's
esophagus that is not reversible with
medical management is:
Esophagectomy.
Total laryngectomy.
Nissen's fundoplication.
Labyrinthectomy.
Older patients with GERD and Barrett's esophagus require
aggressive treatment with proton pump inhibitors and regular
endoscopic examination. If the esophageal erosion does not
reverse with treatment, the surgery of choice is Nissen's
fundoplication, and involves closing any hiatal hernia and restoring
an antireflux barrier.
Which of the following types of gastritis is
associated with Helicobacter pylori and
duodenal ulcers?
Erosive (hemorrhagic) gastritis
Fundic gland gastritis (type A)
Antral gland gastritis (type B)
Aspiring-induced gastric ulcer
Erosive (hemorrhagic) gastritis can be caused by ingestion of
substances that irritate the gastric mucosa. Fundic gland gastritis
(type A) is associated with diffuse severe mucosal atrophy and the
presence of pernicious anemia. Antral gland gastritis (type B) is
the most common form of gastritis, and is associated with
Helicobacter pylori and duodenal ulcers.
Which of the following statements is
accurate about patients diagnosed with
Zollinger-Ellison syndrome?
Peptic ulcer occurs in 95% of patients
diagnosed with Zollinger-Ellison syndrome.
Zollinger-Ellison syndrome is characterized by
gastric hyposecretion, because of dysfunction
of the parietal cells.
Patients with Zollinger-Ellison syndrome with
persistent symptoms that do not respond to
drug treatment should be referred to a
radiologist.
 Treatment of choice for Zollinger-Ellison
In planning care for a patient with
syndrome is a cholecystectomy.
ulcerative colitis, the nurse should
Peptic ulcers occur in 95% of patients with Zollinger-Ellison anticipate which of the following
syndrome. Treatment might include tumor removal and surgical diagnostic procedures?
resection for older persons without surgical risk. Persons with Sigmoidoscopy
Zollinger-Ellison syndrome have gastric hypersecretion, and are
referred to a gastroenterologist if symptoms persist. Colonoscopy

Rectal mucosa biopsy

Which of these agents is a major All of the above

contributing factor in the promotion of
peptic ulcer disorder? Diagnosis of ulcerative colitis is confirmed with the use of
Candida albicans sigmoidoscopy, colonoscopy, and rectal mucosa biopsy.

Staphylococcus infection

Streptococcus infection The most common surgical procedures for

patients with ulcerative colitis are:
Helicobacter pylori infection Subtotal colectomy and ileostomy.

Colostomy and ileo-conduit.

Recurrence of peptic ulcers is related to Helicobacter pylori, use of
NSAIDs, smoking, and continued acid hypersecretion. Laparoscopic gastrectomy.

Segmental resection or colostomy.

Which of the following is not an indication
of diverticulitis? Surgery might be necessary for functional older patients with acute
Fever disease when drug therapy fails and when multiple precancerous
lesions are detected. The most common surgical procedures are
Leukocytosis subtotal colectomy and ileostomy.
Pain

Diarrhea Older patients with longstanding or severe

Crohn's disease can exhibit which of the
Diverticulitis is an infection from colonic diverticula. Fever, following?
leukocytosis, pain, and/or abdominal tenderness might be Hyperalbuminemia
indicators of diverticulitis.
Hypoalbuminemia
Decreased sedimentation rate

Nausea and vomiting

Age-related changes that affect the hematologic

system include: (Select all that apply.)
Correct Answers: Bone marrow in the long bones
decline.

Lymphocyte function, especially cellular immunity,

decreases.

Rationale: At about age 70, the amount of

bone marrow in the long bones declines steadily;
the number of stem cells in the marrow decreases;
and lymphocyte function, especially cellular
immunity, declines.

2. Anemia or insufficient hemoglobin content is

common in older persons. The client's body
compensates for the deficiency by:

Rationale: All anemias result in a loss of

oxygen-carrying capacity of the blood, and produce
generalized hypoxia. The body tries to compensate
by raising the heart and respiratory rates, shunting
blood to vital organs away from the skin, and
increasing blood viscosity in order to supply oxygen
to hypoxic tissues.

3. Which of the following statements accurately

describes normocytic anemia? Normocytic anemia
usually is caused by:
Your Answer: Concurrent chronic illness, such
as chronic heart disease.
Rationale: Normocytic anemia usually is
caused by concurrent chronic illness such as chronic
heart, respiratory, or renal disease or malignancy.
Hemolytic anemia also is a normocytic anemia.
4. The usual treatment for iron-deficiency
anemia includes:
Your Answer: Non-enteric-coated ferrous
sulfate.
Rationale: Once the cause of iron deficiency
has been identified, oral iron therapy is the
preferred treatment. The usual treatment is ferrous
sulfate 325 mg p.o. daily. Enteric-coated and
sustained release formulations should be avoided,
as they are poorly absorbed.
________________________________________
5. Erythropoietin sometimes is administered
subcutaneously to treat which of the following?
(Select all that apply.)
Correct Answer: Clients with anemia and fatigue
related to non-myeloid cancers
Rationale: Cancer in the late stages nearly
always is accompanied by anemia of chronic
disease. Erythropoietin, which stimulates red blood
cell production, is injected subcutaneously, and
sometimes is used to treat anemia and fatigue in
some older clients with non-myeloid cancers.
6. The most common cause of macrocytic
anemia in the older person is B12 or folate
deficiency. Failure to absorb vitamin B12 from the
G.I. tract is called:
Correct Answer: Pernicious anemia.
Rationale: Failure to absorb vitamin B12 from
the G.I. tract is called pernicious anemia, and results
from a lack of intrinsic factor. About 12% of older
people have low serum vitamin B12 levels.
7. An elderly woman is seen at the outclient
clinic by a nurse practitioner for a routine
hematologic evaluation. Which of the following
findings would alert the nurse practitioner of the
need for a pending diagnosis of hemolytic anemia?
Correct Answer: Ongoing use of cephalosporin,
quinidine, triamterene, and aspirin
Rationale: Drugs capable of causing
hemolytic anemia include ibuprofen, L-dopa,
penicillin, cephalosporins, tetracycline,
acetaminophen, aspirin, erythromycin, hydralazine,
insulin, isoniazid, procainamide, quinidine, rifampin,
streptomycin, sulfonamides, methadone,
hydrochlorothiazide, triamterene, and phenacetin.
8. The nurse has provided nutritional teaching
on foods high in folate to a client with folate
deficiency related to malabsorption syndromes and
poor nutrition. Which of the following foods, if
chosen by the client, indicates that the client
understands the teaching?
Correct Answer: Liver and dark green leafy
vegetables
Rationale: Foods high in folate are liver,
orange juice, cereals, whole grains, beans, nuts, and
dark leafy vegetables like spinach.
9. Because older persons can have severe
anemia for a long period of time without detection,
when diagnosed, quick reversal is warranted. Which
of the following orders most likely would be
prescribed at this time?
Your Answer: Ferrous sulfate 325 mg orally
three times a day
Correct Answer: Packed red blood cells followed
by oral furosemide (Lasix)
Rationale: Older persons might have heart
problem that are compounded by severe anemia.
The physician can prescribe blood transfusions to
reverse the severity of the anemia, and a diuretic
such as furosemide (Lasix) orally between units to
prevent fluid overload and the development of
congestive heart failure (CHF).
10. An elderly client is admitted to the hospital
Emergency Department (ED) with complaints of
headache, visual disturbances, and burning pain,
and erythema of the hands and feet. To accurately
diagnose thrombocytopenia, the physician most
likely will order:
Correct Answer: Bone marrow aspiration.
Rationale: Thrombocytopenia is characterized
by an increased number of circulating platelets in
the blood. Accurate diagnosis requires bone marrow
aspiration. Allogenic bone marrow transplantation is
prescribed for younger persons with myelofibrosis. A
splenectomy may be prescribed for persons with
myelofibrosis.
11. When caring for a client with a diagnosis of
thrombocytopenia, the nurse should plan to:
Your Answer: Avoid invasive procedures.
Rationale: Thrombocytopenia is characterized
by an increased number of circulating platelets in
the blood. Older persons with thrombocytopenia are
at significantly increased risk of thrombosis, and
careful monitoring of platelet levels and symptoms
is indicated.
12. In formulating a nursing diagnosis of risk for
infection for a client with chronic lymphoid leukemia
(CLL), nursing measures should include: (Select all
that apply.)
Correct Answers: Placing the client in protective
isolation.
Limiting visitors who have colds and infections.
Ensuring meticulous handwashing by all persons
coming in contact with the client.
Rationale: Chronic lymphoid leukemia (CLL) is
characterized by a proliferation and accumulation of
small, abnormal mature lymphocytes in bone
marrow, peripheral blood, and body tissues.
Infections and fever are frequent complications of
CLL.
13. Which question by the nurse would be
beneficial in assessing the needs of a client with
multiple myeloma?
Correct Answer: "Describe your pain."
Rationale: Multiple myeloma is a malignancy
that results from the overproduction and
accumulation of immature plasma cells in the bone
marrow. Bone pain in the lower back or ribs is the
most common early symptom of multiple myeloma.
14. Which of the following manifestations would
be directly associated with Hodgkin's disease?
Correct Answer: Painless, enlarged lymph nodes
Rationale: Hodgkin's disease usually presents
as painless enlarged lymph nodes. The diagnosis is
made by lymph node biopsy.
15. Which of the following statements made by
the older client indicates risk for immobility and
deep vein thrombosis (DVT) formation?
Your Answer: "It only hurts when I move. I
don't need any pain medication."
Rationale: Postoperative and chronic pain
should be carefully assessed and treated to prevent
older clients from the hazards of immobility. The
older client who says, "It only hurts when I move. I
don't need any pain medication," is at risk for
immobility and DVT formation.
Which of the following is the major mechanism for
maintaining calcium balance in the body?
Correct Answer: Bone remodeling
Rationale: Bone accounts for roughly 99% of
calcium in the body. Throughout life, new bone
continually is deposited and reabsorbed in response
to hormonal, dietary, and mechanical stimuli. When
put together, these processes are called bone
remodeling.
Body alignment does not directly affect calcium
balance. Exercise, particularly weight-bearing
exercise, is important for bone health.
2. Osteoporosis can be defined as:
Your Answer: Loss of bone density.
Rationale: Osteoporosis is loss of bone
density. Specific causes in the elderly include
Vitamin D deficiencies and the use of glucocorticoid
drugs. Phagocytic activity is not a contributing
factor here.
3. Which of the following risk factors are
directly related to common musculoskeletal
problems in older persons? (Select all that apply.)
Correct Answers: Phosphate depletion
Vertebral collapse
Alteration in vitamin D metabolism
Osteoid bone is produced in excess of
mineralization.
4. Which of the following nursing diagnoses
would be assigned priority for the older person with
common musculoskeletal problems?
Correct Answer: Mobility impairment, physical:
Related to pain or discomfort
Rationale: Musculoskeletal status - including
coordination, gait, muscle size and strength, muscle
tone, range of motion, and functional mobility - will
cause altered mobility or impairment in mobility for
patients with common musculoskeletal problems.
5. Which of the following patients with
musculoskeletal problems should the nurse observe
first?
Correct Answer: A client who has just returned
from the operating room (OR)
Rationale: Immediate interventions such as
airway management and vital signs are priority. The
patient with the fractured ankle is requesting pain
medication, but the type of pain is not indicated.
The client with the wet dressing is likely the lowest-
priority client.
6. The physician prescribes alendronate
(Fosamax) and risedronate (Actonel) for a 65-year-
old female for which of the following purposes?
Correct Answer: Inhibiting osteoclastic activity,
and decreasing the incidence of vertebral and non-
vertebral fractures
Rationale: Fosamax and Actonel are potent
drugs that inhibit osteoclastic activity and help to
decrease the incidence of vertebral and non-
vertebral fractures in post-menopausal women. The
actions of these drugs do not include preventing
thrombus formation, binding bile acids, or acting as
an anti-inflammatory agent.
7. Which of the following nursing implications
are important when Fosamax and Actonel are
prescribed for an older patient? (Select all that
apply.)
Correct Answers: Take these drugs on an empty
stomach, first thing in the morning, with water.
Remain upright for 30 minutes and do not eat or
drink anything else for 30 minutes.
 Rationale: Fosamax causes esophagitis if
there is prolonged contact with the esophageal
mucosa, or if it does not pass through the
esophagus completely. Therefore, Fosamax must be
taken with a sufficient amount of water. To promote
complete passage of the drug, it should be taken in
an upright position, to prevent delay of the drug
through the esophagus.
8. A patient is diagnosed with osteomalacia.
The physician prescribes vitamin D replacement
50,000 U/day for two weeks, to be followed by a
daily dose of 800 U/day. The primary goal for this
pharmacological treatment is that:
Your Answer: The patient will achieve effective
remineralization of bone structure.
Rationale: The goal of pharmacological
treatment for osteomalacia is to remineralize the
bone. All older persons with osteomalacia need to
have adequate vitamin D intake to help alleviate
calcium deficiency.
9. Which of the following is a major factor in the
susceptibility and severity of rheumatoid arthritis
(RA)?
Correct Answer: Genetic predisposition
Rationale: The cause of RA is unknown, but it
most likely is due to a variety of unknown
environmental factors, including infectious agents
and chemical exposures, all triggering an
autoimmune response. However, a person's genetic
predisposition is a major factor in both the
susceptibility and the severity of RA.
10. The focus of treatment for rheumatoid
arthritis is related directly to joint damage that is
caused by:
Correct Answer: Pannus.
Rationale: Pannus is vascular granulation
tissue composed of inflammatory cells that erodes
articular cartilage and eventually destroys bones. A
vasculitis usually indicates blood vessel
involvement. Sjögren’s syndrome is due to
inflammatory cells and immune complexes
obstructing secretory ducts and glands. Felty's
syndrome is characterized by rheumatoid arthritis,
hepatosplenomegaly, and leukopenia.
11. The definitive finding for persons with gout
is:
Correct Answer: Urate crystals in synovial fluid.
Rationale: Gout results from the deposit of
urate crystals in a peripheral joint. The definitive
finding for a diagnosis of gout is urate crystals in the
synovial fluid, usually via an arthrocentesis.
Hyperuricemia is excess uric acid in the blood.
Diffuse periarticular erythema is not definitive for
gout.
12. A patient with pseudogout most likely would
complain of pain in what specific area of the body?
Your Answer: Knee
Rationale: The knee joint is the most common
joint affected for most people. Other joints that
might be affected include the shoulder, hip, and
elbow.
13. Which of the following statements is
accurate about hip fractures?
Correct Answer: Extracapsular fractures cause
acute blood loss from the vascular cancellous bone
surfaces, but rarely cause avascular necrosis.
Rationale: Extracapsular fractures cause
acute blood loss from the vascular cancellous bone
surfaces.
14. Which of these findings correlates best with
a diagnosis of Paget's disease?
Correct Answer: Complaints of bone pain
Rationale: Bone pain is the most frequently
reported symptom, described as deep and aching.
Hyperuricemia is present, and the skin usually is
flushed and warm. Nausea and vomiting are a
nonspecific presentation.
15. Principles related to nursing management of
older persons with arthritis include: (Select all that
apply.)
Correct Answers: Promoting a diet with adequate
calcium and vitamin D
Encouraging weight-bearing exercise
Emphasizing the importance of smoking cessation
Rationale: Osteoarthritis is the most common
form of arthritis in the United States, more women
are affected than are men? Recent studies have
determined that aging alone does not cause the
disease; therefore, any woman, by the age of 40,
might show evidence of primary osteoarthritis on x-
ray.
Which of the following persons would most likely be
diagnosed with diabetes mellitus? A 44-year-old:
Correct Answer: African-American woman.
Rationale: Age-specific prevalence of
diagnosed diabetes mellitus (DM) is higher for
African-Americans and Hispanics than for
Caucasians. Among those younger than 75, black
women had the highest incidence.
2. Which of the following factors are risks for
the development of diabetes mellitus? (Select all
that apply.)
Correct Answers: Age over 45 years
Overweight with a waist/hip ratio >1
Maintaining a sedentary lifestyle

Rationale: Aging results in reduced ability of
beta cells to respond with insulin effectively.
Overweight with waist/hip ratio increase is part of
the metabolic syndrome of DM II. There is an
increase in atherosclerosis with DM due to the
metabolic syndrome and sedentary lifestyle.
3. Which laboratory test should a nurse
anticipate a physician would order when an older
person is identified as high-risk for diabetes
mellitus? (Select all that apply.)
Correct Answers: Fasting Plasma Glucose (FPG)
Two-hour Oral Glucose Tolerance Test (OGTT)
Rationale: When an older person is identified
as high-risk for diabetes, appropriate testing would
include FPG and OGTT. A FPG greater than 140
mg/dL usually indicates diabetes. The OGTT is to
determine how the body responds to the ingestion
of carbohydrates in a meal. HbA1C evaluates long-
term glucose control. A finger stick glucose three
times daily spot-checks blood glucose levels.
4. Of which of the following symptoms might an
older woman with diabetes mellitus complain?
Your Answer: Pain intolerance
Correct Answer: Perineal itching
Rationale: Older women might complain of
perineal itching due to vaginal candidiasis.
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Taxonomic Level: Application
________________________________________
5.
When an older adult is admitted to the hospital with
a diagnosis of diabetes mellitus and complaints of
rapid-onset weight loss, elevated blood glucose
levels, and polyphagia, the gerontology nurse
should anticipate which of the following secondary
medical diagnoses?
Your Answer: Pituitary tumor
Correct Answer: Pancreatic tumor
Rationale: The onset of hyperglycemia in the
older adult can occur more slowly. When the older
adult reports rapid-onset weight loss, elevated blood
glucose levels, and polyphagia, the healthcare
provider should consider pancreatic tumor.
Nursing Process: Assessment
Client Need: Physiologic Integrity, Reduction of Risk
Potential
Taxonomic Level: Evaluation
________________________________________
6.
The principal goals of therapy for older patients who
have poor glycemic control are:
Your Answer: Improving self-care through
education.
Correct Answer: All of the above.
Rationale: The principal goals of therapy for
older persons with diabetes mellitus and poor
glycemic control are enhancing quality of life,
decreasing the chance of complications, improving
self-care through education, and maintaining or
improving general health status.
Nursing Process: Planning
Client Need: Safe, Effective Care Environment
Taxonomic Level: Comprehension
________________________________________
7.
Which of the following is accurate pertaining to
physical exercise and type 1 diabetes mellitus?
Your Answer: Strenuous exercise is beneficial
when the blood glucose is high.
Correct Answer: Physical exercise can slow the
progression of diabetes mellitus.
Rationale: Physical exercise slows the
progression of diabetes mellitus, because exercise
has beneficial effects on carbohydrate metabolism
and insulin sensitivity. Strenuous exercise can cause
retinal damage, and can cause hypoglycemia.
Insulin and foods both must be adjusted to allow
safe participation in exercise.
Nursing Process: Application
Client Need: Physiologic Integrity
Taxonomic Level: Analysis
________________________________________
8.
A diabetic patient experiencing a reaction of
alternating periods of nocturnal hypoglycemia and
hyperglycemia might be manifesting which of the
following?
Your Answer: Brittle diabetes
Correct Answer: Somogyi phenomenon
Rationale: Somogyi phenomenon manifests
itself with nocturnal hypoglycemia, followed by a
marked increase in glucose and increase in ketones.
Nursing Process: Analysis
Client Need: Physiologic Integrity
Taxonomic Level: Analysis
________________________________________
9.
The primary purpose for sulfonylureas, such as long-
acting glyburide (Micronase), is to:
Your Answer: Improve insulin sensitivity and
decrease hyperglycemia.
Correct Answer: Stimulate the beta cells of the
pancreas to secrete insulin.
Rationale: Sulfonylureas such as glyburide
are used only with patients who have some
remaining pancreatic-beta cell function. These
drugs stimulate insulin secretion, which reduces
liver glucose output and increases cell uptake of
glucose, enhancing the number of and sensitivity of
cell receptor sites for interaction with insulin.
Nursing Process: Analysis
Client Need: Physiologic Integrity, Pharmacologic
Therapy
Taxonomic Level: Knowledge
________________________________________
10.
One of the benefits of Glargine (Lantus) insulin is its
ability to:
Your Answer: Simplify the dosing and better Client Need: Physiologic Integrity
control blood glucose levels during the day. Taxonomic Level: Analysis
Correct Answer: Release insulin evenly ________________________________________
throughout the day and control basal glucose levels. 12.
Which of the following diagnostic studies is done to
Rationale: Glargine (Lantus) insulin is determine the size and composition of the thyroid
designed to release insulin evenly throughout the gland?
day and control basal glucose levels. Your Answer: Thyroid scan with RAI 123I
Nursing Process: Evaluation Correct Answer: Ultrasonography
Client Need: Physiologic Integrity, Pharmacologic
Therapy Rationale: Although thyroid scans frequently
Taxonomic Level: Evaluation are done to evaluate the thyroid gland, I 123 is used
________________________________________ to destroy overactive thyroid cells such as are seen
11. in thyroid cancer. Ultrasonography can be used
A frail elderly patient with a diagnosis of type 2 early in the evaluation process to rule out Graves'
diabetes mellitus has been ill with pneumonia. The disease, nodular goiter, or other thyroid dysfunction.
client's intake has been very poor, and she is Nursing Process: Assessment
admitted to the hospital for observation and Client Need: Physiologic Integrity, Reduction of Risk
management as needed. What is the most likely Potential
problem with this patient? Taxonomic Level: Knowledge
Your Answer: Diabetic ketoacidosis is ________________________________________
occurring. 13.
Correct Answer: Hyperglycemic hyperosmolar Which of the following is a drug of choice for
non-ketotic coma hyperthyroidism (Graves' disease)?
Your Answer: Digoxin (Lanoxin)
Rationale: Illness, especially with the frail Correct Answer: Propylthiouracil (PTU)
elderly patient whose appetite is poor, can result in
dehydration and HHNC. Insulin resistance usually is Rationale: Propylthiouracil (PTU) initially is
indicated by a daily insulin requirement of 200 units given in divided doses, and functions to block
or more. Diabetic ketoacidosis, an acute metabolic thyroid hormone synthesis.
condition, usually is caused by absent or markedly Nursing Process: Assessment
decreased amounts of insulin. Client Need: Physiologic Integrity, Pharmacologic
Nursing Process: Analysis Therapy
Taxonomic Level: Knowledge
________________________________________
14.
The nurse is caring for a patient with a diagnosis of
hypothyroidism. Which nursing diagnosis should the
nurse most seriously consider when analyzing the
needs of the patient?
Your Answer: Diarrhea related to increased
peristalsis
Correct Answer: Hypothermia related to slowed
metabolic rate
Rationale: Thyroid hormone deficiency results
in reduction in the metabolic rate, resulting in
hypothermia, and does predispose the older adult to
a host of other health-related issues. One quarter of
affected elderly experience constipation.
Nursing Process: Planning
Client Need: Physiologic Integrity, Reduction of Risk
Potential
Taxonomic Level: Analysis
________________________________________
15.
Which of the following medications are most likely
to cause hypothyroidism? (Select all that apply.)
Your Answer: Acetylsalicylic acid (aspirin)
Correct Answers: Acetylsalicylic acid (aspirin)
Furosemide (Lasix)
Rifampin (Rifadin)
Nursing Process: Assessment
Client Need: Physiologic Integrity, Pharmacologic
Therapy
Taxonomic Level: Knowledge
Which of the following are least likely to be early
signs of cardiac problems in older persons? (Select
all that apply.)
Your Answer: Mental status changes
Correct Answers: Mental status changes
Agitation
Frequent falls
Rationale: Many cardiovascular functions are
complicated in that they involve many other
systems. Mental status changes, agitation, and falls
can be early signs of cardiac problems in the older
person. Changes in function in the GI system are not
typical signs of a cardiac problem.
Integrated Process: Nursing Process; Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk
________________________________________
2.
A patient has been diagnosed with Right-Sided
Congestive Heart Failure, and is confused about
return of deoxygenated blood from the tissue. To
clarify the confusion, which chamber of the heart
receives blood from systemic circulation?
Your Answer: Right atrium
 Rationale: The right atrium is a thin-walled
structure that receives deoxygenated blood from all
the peripheral tissues by way of the superior and
inferior vena cava and from the heart muscle by
way of the coronary sinus.
Integrated Process: Teaching Learning
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
3.
It is important that the nurse be knowledgeable
about cardiac output in order to:
Your Answer: Determine the electrical activity
of the myocardium.
Correct Answer: Evaluate blood flow to peripheral
tissues.
Rationale: Blood flow to the tissues is
measured clinically as the cardiac output, and
assists to predict tissue perfusion. Electrical activity
is evaluated more effectively by EKG. While the
cardiac output is important for perfusion and
oxygenation of tissues, the oxygen saturation would
provide more valuable information. Nutritional
changes would be targeted to sodium and would
depend on symptoms of disease.
Integrated Process: Nursing Process; Planning
Cognitive Level: Evaluation
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
4.
Nurses can best help older clients prevent
hypertension by teaching:
Your Answer: Low-fat, low-cholesterol diets.
Correct Answer: How to maintain a normal blood
pressure.
Rationale: Hypertension is a major risk factor
for other cardiovascular conditions. In persons older
than 50, systolic blood pressure greater than 140
mm Hg is a much more important cardiovascular
disease risk factor than is diastolic blood pressure.
The risk of cardiovascular disease, beginning at
115/75 mm Hg, doubles with each increment of
20/10 mm Hg. Answers 1, 2, and 3 are important
elements to include in education of a patient with
blood pressure elevation, and are included in the
correct answer.
Integrated Process: Nursing Process;
Implementation
Cognitive Level: Evaluation
NCLEX-RN Test Plan: Health Maintenance and
Promotion
________________________________________
5.
Modification of lifestyle behaviors to help manage
hypertension does not include which of the
following? (Select all that apply.)
Your Answer: The DASH diet
Correct Answer: Alcohol intake with meals
Rationale: Weight loss of even 10 pounds;
fruits, vegetables, and whole grains; the DASH diet;
and a daily exercise regimen will help reduce high
blood pressure. Alcohol intake with meals should be
reduced to help manage high blood pressure.
Integrated Process: Nursing Process; Planning
Cognitive Level: Synthesis
NCLEX-RN Test Plan: Health Maintenance and
Promotion
________________________________________
6.
A patient receiving the drug simvastatin (Zocor)
should be taught this medication helps to prevent
coronary heart disease by:
Your Answer: Increasing triglycerides.
Correct Answer: Controlling lower-density
lipoprotein.
Rationale: The Heart Protective Study has
also shown that controlling low-density lipoprotein
(LDL) with simvastatin (Zocor) assists in the
prevention of coronary heart disease by raising HDL.
Responses 1, 3, and 4 are incorrect.
Integrated Process: Teaching Learning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity:
Pharmacological and Parenteral Therapies
________________________________________
7.
Which of the following are not direct causes of
chronic ischemic pain? (Select all that apply.)
Your Answer: Acid reflux
Correct Answers: Aortic stenosis
Acid reflux
Pulmonary embolus
Rationale: Herpes zoster (shingles) manifests
as a vesicular rash along a dermatome, not chronic
ischemic pain.
Integrated Process: Nursing Process; Evaluation
Cognitive Level: Evaluation
NCLEX-RN Test Plan: Physiological Integrity;
Physiological Adaptation
________________________________________
8.
Older clients experiencing anginal pain with
complaints of fatigue or weakness usually are
medicated with which of the following types of
medication?
Your Answer: Sublingual nitroglycerin
Rationale: Angina frequently is managed with
sublingual nitroglycerin, which causes vasodilation
and increases blood flow to the coronary arteries.
Cardiac glycosides are used to treat heart failure,
and morphine is used to treat myocardial infarction.
The HMG-CoA reductase inhibitors are used for
patients with type 2 diabetes mellitus.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological Therapy
________________________________________
9.
Which of the following diagnostic studies most likely
would confirm a myocardial infarction?
Your Answer: Creatinine kinase (CK)
Correct Answer: Troponin T levels
Rationale: CK-MB elevates 4-6 hours after
tissue necrosis. Troponin levels rise 6-8 hours after
the infarct (tissue necrosis) but also can occur with
other types of tissue damage. Myoglobin also
elevates, but to a lesser degree. WBC levels elevate
with an inflammatory response. Troponin levels are
more elevated than are the other cardiac enzymes,
are more specific to cardiac tissue, and rise 6-8
hours after the infarct (tissue necrosis).
Integrated Process: Nursing Process: Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
10.
A client with post-myocardial infarction develops
acute bacterial pericarditis. Which of the following
medications would the physician most likely
prescribe as the primary drug?
Your Answer: Acetaminophen (Tylenol)
Correct Answer: Ticarcillin disodium (Ticar)
Rationale: Acute bacterial pericarditis is a
complication that can occur post-myocardial
infarction. Acute bacterial pericarditis usually
requires antibiotics. NSAIDs usually are prescribed
to relieve pain from the inflammatory process. If the
NSAIDs do not relieve pain within 48 to 96 hours,
corticosteroids are ordered. There is no mention of
pain in the stem of the question. Trisoralen is used
to repigment skin for persons with vitiligo.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN: Physiological Integrity; Pharmacological
Therapy
________________________________________
11.
Which of the following diagnostic tests is preferred
for evaluating heart valve function?
Your Answer: Echocardiogram
Rationale: The echocardiogram is the
preferred test to evaluate heart valves, because it
allows the visualization of the valves as they open
and close. A chest x-ray will determine the size of
the heart, the duplex measures blood flow through
major arteries, and an electrocardiogram identifies
electrical activity.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
12.
An elderly client is being monitored for evidence of
congestive heart failure. To detect early signs of
heart failure, the nurse would instruct the certified
nursing attendant (CNA) to do which of the following
during care of the patient?
Your Answer: Observe electrocardiogram
readings and report deviations to the nurse.
Correct Answer: Accurately weigh the patient,
and report and record the readings.
 Rationale: Due to fluid accumulation, an
expanded blood volume can result when the heart
fails. Body weight is a sensitive indicator of water
and sodium retention, which will manifest itself with
edema, dyspnea - especially nocturnal - and pedal
edema. Patients also should be instructed about the
need to perform daily weights upon discharge to
monitor body water. It is not within the role of the
CNA to monitor ECG readings, and ambulation is not
an assessment. Vital signs every 15 minute are not
necessary for this level of patient care.
Integrated Process: Communication and
Documentation
Cognitive Level: Planning
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
13.
Which of the following drug classifications should
the nurse question if prescribed for a person with
congested heart failure (CHF)?
Your Answer: Beta-adrenergic blocker
Correct Answer: Rosiglitazone (Avandia)
Correct answer: Thiazolidinediones, like
rosiglitazone (Avandia), are glucose-reducing drugs
that are prescribed for persons with type 2 diabetes
mellitus. ACE inhibitors, such as Lisinopril, are first-
line drugs used to treat CHF. Propranolol (Inderal), a
beta blocker, has remained one of the most widely
used beta-blocking drugs. It blocks both beta1 and
beta2 receptors in various organs, resulting in
reduction of heart rate and the force of contraction,
and suppresses impulse conduction through the AV
node, all of which slows the progression of the
disease process. Carvedilol (Coreg) is another beta-
adrenergic blocker used to treat heart failure.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological Therapy
________________________________________
14.
A common arrhythmia found in some older clients is
chronic atrial fibrillation. Based on the nurse's
knowledge of the disease pathology, which of the
following prescriptions should the nurse expect to
be ordered?
Your Answer: Warfarin sodium (Coumadin)
Rationale: Chronic atrial fibrillation places a
patient at high risk for clot formation. Warfarin
sodium frequently is ordered as an anti-coagulant.
Aspirin will not prevent clots associated with atrial
fibrillation. Zocor is used to lower LDL and increase
HDL. Navelbine is an anti-neoplastic.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological Therapy
________________________________________
15.
Which of the following assessments would be an
important finding for a patient with arterial disease?
Your Answer: Intermittent claudication with
exercise

Rationale: Intermittent claudication is a
common finding in persons with arterial disease,
usually due to progression of atherosclerosis and
alteration of tissue perfusion to the extremities. In
venous disease, valves of the veins in the
extremities become incompetent, resulting in higher
pressures than normal in the veins. The pressure is
transmitted to the capillaries of the lower
extremities, resulting in thickening and non-pitting
edema of tissues around the ankles. Prolonged
thickening results in the red blood cells' being
pressed outside the capillaries. The cells eventually
break down, resulting in collection of hemosiderin
deposits being collected in the area. Altered
sensation to touch would be due to neuropathic
changes commonly found with diabetes mellitus.
Integrated Process: Nursing Process: Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
Which of the following is a normal finding when
assessing the respiratory system of an elderly
client?
Your Answer: A decreased anteroposterior
diameter and increased alveolar surface
Correct Answer: Decreased mobility of the thorax
and increased chest wall stiffness
Rationale: The normal aging process is
accompanied by physiologic changes to the
respiratory system such as stiffening of elastin and
collagen tissues, increased alveolar diameter,
decreased alveolar surface, and increased chest
wall stiffness. Bronchovesicular breath sounds are
heard over major bronchi where fewer alveoli are
located.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
2.
An older client is receiving postural drainage
treatments but is unable to expel the secretions.
The client is confused, and having difficulty
following instructions. The best response by the
nurse would be to:
Your Answer: Administer humidified oxygen.
Correct Answer: Suction out the secretions.
Rationale: Postural drainage loosens
secretions, which patients usually expectorate when
loosened. Since the client is confused, and cannot
follow instructions, the nurse must suction the
secretions to enhance effective breathing.
Integrated Process: Nursing Process;
Implementation
Cognitive Level: Synthesis
NCLEX-RN Test Plan: Physiological Integrity:
Physiological Adaptation
________________________________________
3.
Chest percussion has been ordered for a client on
bedrest with respiratory infections and increased
secretions. The nurse should use which of the
following hand positions to administer chest
percussion?
Your Answer: Cupped-hand position
Rationale: Cupped-hand position enhances
vibration, which helps to loosen secretions, clear
airway, and improve gas exchange. The flat, fisted,
and flexed hand positions can cause pain and harm
the patient.
Integrated Process: Nursing Process;
Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
4.
All of the following nursing diagnoses are important
for a client with chronic pulmonary emphysema
(COPD). Which would receive priority when planning
nursing interventions?
Your Answer: Activity intolerance
Correct Answer: Impaired gas exchange
Rationale: Physical assessment of older
persons with COPD might find ineffective airway
clearance, but the classic physiology alteration is
the destruction of the alveoli with resulting
complications. Therefore, impaired gas exchange
always is present.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Adaptation
________________________________________
5.
The nurse is teaching a group of older clients about
the functions of the respiratory tract as part of
health promotion. Which statement made by
patients would indicate a need for further teaching?
Your Answer: "Parts of our respiratory system
help us produce speech and better communication."
Correct Answer: "The lungs keep our blood
pressure in normal range, so we can breathe
better."
Rationale: The respiratory system performs
several secondary functions, including maintenance
of acid-base balance, production of speech, and
maintenance of body water and heat balance. The
heart and cardiovascular system are responsible for
the blood pressure.
Integrated Process: Teaching Learning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
6.
Which of the following diagnostic studies is most
helpful in determining the presence of asthma?
Your Answer: Spirometry
Correct Answer: Pulmonary function tests (PFTs)
Rationale: Pulmonary function tests are the
most reliable way to diagnose asthma and
differentiate it from other illnesses like COPD. Large
numbers of eosinophils indicate an allergic
component and a predictor of asthma. Spirometry is
used to measure the volume of air expired in one
second from maximum inspiration. Incentive
spirometer is used for breathing exercises with
patients who have respiratory problems; pre- and
postop patients also benefit from the use of the
incentive spirometer.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
7.
Corticosteroid therapy is the most effective anti-
inflammatory treatment for asthma.
The nurse administering oral corticosteroids should
observe the client for adverse effects of: (Select all
that apply.)
Your Answer: Hyponatremia.
Correct Answers: Increase in intraocular pressure.
Pathologic fractures.
Rationale: Corticosteroids accelerate
osteoporosis and increase the risk for pathologic
fractures. Corticosteroids result in sodium retention
(not hyponatremia), which causes fluid retention,
which could result in increased intraocular pressure.
Weight gain, not weight loss, is a side effect of
corticosteroid therapy.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Evaluation
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological and Parenteral
________________________________________
8.
Which of the following medications should the nurse
anticipate the physician would prescribe for
"rescue" from sudden-onset wheezing, tightness in
the chest, or shortness of breath due to an asthma
diagnosis?
Your Answer: (blank)
________________________________________
9.
Which of the following interventions would be a
priority in the plan of care for the person with
pulmonary emphysema? (Select all that apply.)
Your Answer: Maintaining hydration status
Correct Answer: Low-flow oxygen via face mask
Rationale: Patients with pulmonary
emphysema have a low pO2 that keeps them alive
(their hypoxic drive). High levels of oxygen would
diminish their response to breathe. Persons with
pulmonary emphysema have narrowed airways.
Aminophylline is a bronchodilator that works to
open narrowed airways and improve airflow and gas
exchange. Patients with pulmonary emphysema
often have respiratory infection, and are treated
with broad-spectrum antibiotics, like ampicillin.
These patients often are dehydrated, and need
secretions liquefied for easier expectoration.
Limiting fluids would help decrease airway
clearance and therefore diminish gas exchange.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Physiological Adaptation
________________________________________
10.
A patient has been instructed in pursed-lip
breathing. The patient asks the nurse the purpose
behind this breathing pattern. The nurse's best
response to this question would be:
Your Answer: "Pursed-lip breathing prevents
airway collapse and enhances effective breathing."
Rationale: Pursed-lip breathing during
exhalation is a useful technique for preventing early
airway collapse.
Integrated Process: Teaching/Learning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
11.
During an initial interview, the charge nurse informs
a client that even though he is the youngest client
in the nursing home, he will be required to
participate in activities with older patients. He tells
the nurse that he can handle the interaction, but will
need the nurse's help during the initial adjustment.
The responses from the patient indicate which of
the following?
Your Answer: A stressful situation in which
challenge and gain are anticipated
Rationale: Selye believes that it is not just the
"bad" things in life that cause stress, but the "good"
things as well. An effective coping strategy is
drawing strength from adversity.
Integrated Process: Caring
Cognitive Level: Synthesis
NCLEX-RN Test Plan
________________________________________
12.
Which of the following measures is the most
important action in preventing the transmission of
pulmonary tuberculosis?
Your Answer: Adequate ventilation of rooms
Rationale: Pulmonary tuberculosis is an
airborne disease that is spread from person to
person by droplets when an infected person coughs,
sneezes, speaks, sings, or laughs. Responses 1, 2,
and 3 are not adequate interventions for the
prevention of tuberculosis. Having rooms with
adequate ventilation of non-recirculated air is the
best plan.
Integrated Process: Nursing Process; Planning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
13.
Clients identified with pulmonary tuberculosis due to
M. tuberculosis usually are placed on Isoniazid (INH)
to prevent active disease. Client teaching prior to
discharge from a clinic setting would place priority
on which of the following post-discharge
instructions?
Your Answer: Follow-up care will include
reading a PPD test within 72 hours.
Correct Answer: Liver function tests should be
monitored routinely.
Rationale: Isoniazid causes hepatotoxicity;
therefore, persons on Isoniazid should have liver
function tests routinely monitored. After diagnosis of
TB, a PPD always will be positive. Headache and
weight gain are not priorities.
Integrated Process: Teaching Learning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological Therapies
________________________________________
14.
Patients with suspicious masses in the lung as seen
on chest x-ray could have which of the following
diagnostic studies to provide information on soft
tissue masses?
Your Answer: Pulmonary function tests (PFTs)
Correct Answer: CAT scan and magnetic
resonance imaging (MRI)
Rationale: The chest x-ray usually is the first
examination that the physician will order. Suspicious
masses seen on the chest x-ray could signal the
need for CAT scan and an MRI to provide additional
information about soft tissue masses. The
gastrograffin swallow test would be used to
diagnose an esophageal rupture, while a wedge
resection would be treatment for a lung mass.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
15.
A patient is being treated for community-acquired
pneumonia. Which of the following drugs should the
nurse question, related to this treatment?
Your Answer: Amoxicillin (Amoxil)
Correct Answer: Chlorzoxazone (Paraflex)
Rationale: Chlorzoxazone is a skeletal muscle
relaxant. Erythromycin, azithromycin, and
amoxicillin are oral antibiotics recommended to
treat older persons with community-acquired
pneumonia.
Integrated Process: Nursing Process; Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological and Parenteral Therapies
One of the challenges in meeting the nutritional
needs of the elderly is that the elderly:
Your Answer: Have a decreased need for
almost all nutrients.
Correct Answer: Have decreased caloric needs
but constant or increased needs for vitamins and
minerals.
Rationale: A decreasing metabolic rate (or
resting energy expenditure) means fewer calories
are required, but the DRI for most nutrients remains
unchanged or might be increased in the elderly,
necessitating careful dietary planning to meet those
needs. Loss of interest in food might mean
physiologic problems exist. Dental problems for the
elderly are not nearly as common today as they
were a generation ago.
Nursing Process: Planning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
2.
When an elderly person is hospitalized with
pneumonia, what would be the best action by the
nurse to encourage eating?
Your Answer: Secure an order for a daily
multivitamin to stimulate appetite.
Correct Answer: Provide small, more frequent
meals.
Rationale: An elderly person is more likely to
eat if portions are small, more frequent, and
nutrient-dense, as opposed to a full meal tray three
times a day. A vitamin will not stimulate appetite.
Snacks are not necessary if small, frequent meals
are provided. Hydration is always important, but
fluids do not provide the nutrients needed for
healing.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
3.
What preventive measures might the nurse teach
the elderly to prevent constipation?
Your Answer: Drink coffee or tea only in the
morning.
Correct Answer: Drink a glass of water several
times a day.
Rationale: Adequate fluid intake, along with
adequate fiber, are the best dietary measures to
prevent constipation. Daily stool softeners can lead
to dependency on them for bowel movements.
Chewing is important, but will not prevent or control
constipation. Coffee or tea taken only once per day
will not supply enough fluid to prevent constipation.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
4.
What type of diet will the nurse recommend to most
healthy elderly clients?
Your Answer: A diet low in fat and protein
Correct Answer: A diet high in complex
carbohydrates and fiber
Rationale: Complex carbohydrates and fiber
provide some protein in addition to some necessary
vitamins and minerals. They aid digestion, and have
a lower glycemic load. For an active, healthy elderly
person, 1,200 calories per day will not be adequate
to prevent weight loss. Inadequate protein does not
allow for tissue maintenance and repair. High-
carbohydrate diets do not provide adequate balance
to caloric distribution.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
5.
An elderly client has been admitted to a nursing
home, and the nurse completes an assessment.
Which finding might lead the nurse to suspect a
nutritional alteration?
Your Answer: Moist conjunctiva
Correct Answer: Ridged nails
Rationale: Ridged, spoon-shaped nails are
signs of long-term nutritional deficiencies. Shiny hair
and moist conjunctiva are signs of nutritional
balance. A pale tongue, in the absence of other
pathology, does not signify nutritional inadequacy.
Nursing Process: Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
6.
The elderly client who wants to take an herbal
supplement for arthritis symptoms should be
advised to:
Your Answer: Verify their effectiveness with
friends or family members who have taken them.
Correct Answer: Consult their healthcare provider
about possible interactions with current
medications.
Rationale: Herbal supplements might be of
unknown quality, and also might interact with
medications. Serious side effects are more likely
when used with some prescription medications.
Family and friends are not the best source of health
information.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
7.
The nurse who is preparing to insert a nasogastric
tube for enteral feedings recognizes that this
intervention is used for elderly clients who:
Your Answer: Cannot adequately metabolize
nutrients.
Correct Answer: Are unable to ingest food.
Rationale: Enteral support is used for clients
who are unable to ingest adequate amounts of food
for tissue maintenance and repair. Digestion occurs
in the GI tract, and metabolism occurs at the cellular
level. The gag reflex is not related to nutritional
support unless it is present as a result of a medical
condition; a CVA, for example.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
8.
When working with elderly clients who require an
increased consumption of complete protein, the
nurse recommends:
Your Answer: Iron-fortified cereal. Rationale: Dietary assessment and early
Correct Answer: 2% milk. intervention can improve overall quality of life and
possibly prevent disease or illness. Most acute
Rationale: After eggs and meats, milk is the conditions are not treated primarily by dietary
best source of complete protein. Legumes, cereal, intervention. Digestion occurs in the GI tract, and
and bread have some protein, but it is incomplete metabolism occurs at the cellular level.
protein. Nursing Process: Implementation
Nursing Process: Planning Cognitive Level: Analysis
Cognitive Level: Knowledge NCLEX-RN Test Plan: Health Promotion and
NCLEX-RN Test Plan: Health Promotion and Maintenance
Maintenance ________________________________________
________________________________________ 11.
9. Which nutrient is most likely to be deficient in
An appropriate dietary intervention for an elderly elderly residents of nursing homes?
client with dysphagia is: Your Answer: Protein
Your Answer: Thicken thin liquids. Correct Answer: Vitamin D

Rationale: Dysphagia means difficulty with
swallowing. Liquids that are thickened are easier to
swallow and less likely to cause the client to choke
or gag. The frequency or temperature of foods does
not affect the ability to swallow.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
10.
A primary goal of dietary intervention for the elderly
is to:
Your Answer: Improve digestion and
metabolism.
Correct Answer: Maintain quality of life.
Rationale: The elderly have greater need for
vitamin D due to decreased absorption, decreased
dietary intake, and lack of exposure to sunlight.
Calcium, protein, and vitamin K are more readily
obtained through dietary means.
Nursing Process: Evaluation
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
12.
The loss of lean muscle mass that occurs with aging
can be diminished or reversed by:
Your Answer: Small doses of anabolic
hormones.
Correct Answer: Strength-training exercises.

Rationale: Resistance exercises, such as
lifting weights, have been shown to increase muscle
mass in the elderly. Anaerobic exercises, high-
protein diets, and anabolic steroids are not effective
in reducing loss of muscle mass or increasing
muscle mass.
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
13.
The absorption of iron in the elderly can be
diminished in the presence of:
Your Answer: Vitamin C.
Correct Answer: Antacids.
Rationale: Anything that interferes with the
production of hydrochloric acid interferes with the
absorption of iron, and should be avoided when
trying to promote iron absorption. Diuretics, vitamin
C, and milk do not affect iron absorption.
Nursing Process: Implementation
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
14.
When serving a meal to elderly residents of a
nursing home, the nurse should:
Your Answer: Open cartons and cut food into
bite-sized portions.
Correct Answer: Provide adaptive equipment as
needed.
Rationale: The use of adaptive equipment
allows residents to be as independent as possible at
mealtime. It is important to allow clients to do as
much as possible for themselves.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
15.
A major predictor of morbidity and mortality in the
elderly is:
Your Answer: Polypharmacy.
Correct Answer: Unintentional weight loss.
When an elderly male client states he has
pain, the nurse recognizes that:
Your Answer: The client probably has
significant pain, because many elderly understate
and under-report pain.
Rationale: Many elderly fear being labeled as
complainers, so they frequently fail to mention
having pain, or diminish its significance to them.
The elderly are no more prone to exaggerate pain
than is any other age group. The elderly do not lose
pain receptors, and the most frequent reason for
healthcare visits is to manage chronic health
conditions.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
2.
When the family of an elderly resident at the
nursing home wants to file a complaint about the
improper use of restraints, the nurse should suggest
that they:
Your Answer: Contact the attorney retained by
the nursing home administrator.
Correct Answer: Call the ombudsman assigned to
the nursing home.
Rationale: The improper use of restraints is a
valid reason for contacting the nursing home
ombudsman, whose name and phone number
should be readily available to residents and families.
The other options do not identify the appropriate
individual to handle the family’s request to file a
complaint.
Nursing Process: Evaluation
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
3.
The nurse who understands the Patient Self-
Determination Act of 1990 understands that:
Your Answer: Medicare coverage is extended
for those elderly who suffer from catastrophic
conditions.
Correct Answer: Elderly clients who are
competent have the right to make informed
decisions regarding healthcare.
Rationale: This federal law governs anyone’s
ability to give informed consent after being fully
informed about the options, benefits, or risks of any
given treatment. The other options might be
desirable; they are not part of the Patient Self-
Determination Act of 1990.
Nursing Process: Planning
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
4.
Which of the following will the nurse want to include
when planning a functional assessment of an elderly
client?
Your Answer: A social worker
Rationale: A functional assessment is
conducted by an interdisciplinary team, and may be
performed while a client is an inpatient at a
hospital, but also may be conducted in an office
setting. All of the other things might be nice to have
when the assessment is conducted, but the nurse
does not need to have them.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
5.
When a nursing home uses the Minimum Data Set
(MDS), the nurse is assured that:
Your Answer: Regular dental care is being
provided.
Correct Answer: The nursing home is meeting
federal regulations.
Rationale: The MDS provision of the Omnibus
Budget Reconciliation Act of 1987 requires
assessment of all residents using the criteria of the
MDS. The MDS does not address the other options.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
6.
The primary purpose for documenting an adverse
event, such as a fall, is to:
Your Answer: Record unusual occurrences.
Correct Answer: Improve the quality of care.
Rationale: Adverse events are always
opportunities for quality improvement, and
documentation should lead to system analysis and
improvement. Careful records need to be kept to
document follow-up with respect to staff
development and client outcomes; however, the
ultimate goal is to improve the quality of care.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
7.
Which of the following nursing actions will help
maintain safety for the elderly?
Your Answer: Encourage independence.
Correct Answer: Orient to new surroundings.
Rationale: Safety is a priority need for the
elderly, especially when in new surroundings, such
as a hospital or long-term care facility; they can
become disoriented when they cannot easily locate
familiar places like the bathroom. The nursing
actions in the other actions are desirable but are not
primarily for client safety.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
8.
The nurse observes the following actions and
recognizes that a breech of confidentiality is evident
when a colleague:
Your Answer: Uses the phone to confer with a
physician’s nurse about a client’s change of
condition.
Correct Answer: Throws unofficial lab results into
the regular trash.
Rationale: Client information may be shared
with those who need to know it. When information
with a client’s name is thrown in the regular trash, it
might be found and read by anyone.
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
9.
When an elderly person agrees with a physician that
a do not resuscitate (DNR) order is appropriate, that
person is said to be:
Your Answer: In need of a living will.
Correct Answer: Competent.
Rationale: When a physician explains to a
client that additional care is futile, the client who is
competent might not agree. Based on the wishes of
the competent client, an order may be written.
Giving assent suggests that the client cannot give
fully informed consent. The competent client has full
decisional capacity, and does not need a living will
unless he so chooses.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
10.
When obtaining a social history from an elderly
client, the nurse will ask about:
Your Answer: Problems with memory,
judgment, and thought.
Correct Answer: Living arrangements and family
dynamics.
Rationale: A social history has to do with
social support systems and interpersonal
relationships. The other choices presented are dealt
with in a functional assessment.
Nursing Process: Assessment
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Psychosocial Integrity
Primary prevention of elder mistreatment is a
healthcare goal. The nurse recognizes that one of
the risk factors often present in elder mistreatment
situations is:
Your Answer: Caregiver independence.
Correct Answer: Elder dependency.
Rationale: One of the primary characteristics
in elders who have been mistreated is dependency
on others for performance of activities of daily
living. Dependence can lead to caregiver strain and
then mistreatment. Home care is not a risk factor
for mistreatment. Caregiver independence is not
related to mistreatment of the elderly. Elders who
have minimal family support can feel abandoned.
Nursing Process: Analysis
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
2.
A home care nurse found an elderly client with
multiple bruises on both arms and the trunk. After
the client denied the spouse was responsible, the
rationale the nurse used for reporting the suspicion
of abuse was:
Your Answer: The client was too afraid to
report the spouse.
Correct Answer: Reporting suspected abuse is an
ethical responsibility of the nurse.
Rationale: The nurse has an ethical and legal
responsibility to report suspected abuse to
designated authorities for investigation. Because
the nurse has this responsibility, legal liability is not
an issue, nor are the denials by the client grounds
for not reporting the suspicion of abuse.
Nursing Process: Analysis
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
3.
When a nurse determines with a high degree of
confidence that an elderly homebound client has
been mistreated, an appropriate intervention would
be:
Your Answer: Consulting with the physician
about admission to the hospital for a thorough
assessment of the client.
Rationale: It is appropriate to admit a client to
the hospital for a thorough assessment in a safe
environment, and it serves as an immediate way to
remove the client from the situation. Social Services
will conduct an investigation, but the nurse has a
responsibility to formulate a plan of care for the
client. The caregiver might not be responsible for
the abuse, so it would not be appropriate to suggest
a new caregiver. Police surveillance is not done for
suspected mistreatment.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
4.
Which of the following situations could be the
source of an ethical dilemma for the nurse with
respect to elder mistreatment?
Your Answer: The family sues the nurse for
reporting abuse.
Correct Answer: The elderly person decides to
return to the abusive setting.
Rationale: The nurse recognizes an ethical
dilemma is posed when a competent adult chooses
to return to the setting in which abuse occurred,
because there is a high likelihood of abuse being
repeated. The elderly person who is not competent
will not be allowed to make decisions about the
living situation. Injury is not a source of an ethical
dilemma, nor is legal action taken against a nurse.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
5.
An elderly person reports all of the following
experiences to the nurse. Which of the reported
experiences is the most likely indicator of
exploitation of the elderly person?
Your Answer: The client is being threatened
with admission to a nursing home.
Correct Answer: There isn’t any money available
to make a weekly donation at church.
Rationale: When the elderly are exploited,
others take advantage of them, almost always with
respect to money matters. The exploiters might not
be family members. Failure of family to visit and
forced attendance of family events are not
exploitation. Threats can be attempts at coercion
but are not exploitation.
Nursing Process: Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
6.
The nurse suspects that a home health aide who
comes into the home every day to provide basic
hygiene care is abusing an elderly client. What is
the best way to gather more information about the
situation to confirm suspicions of abuse?
Your Answer: Interview the client in private.
Rationale: The best method of getting
information is to interview the client in a private
setting. Depending on the responses of the client,
the nurse can develop a plan for how to proceed.
The nurse then can consult the family or involve a
social services agency.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
7.
What data would help support a nursing diagnosis of
elder mistreatment in the domestic setting?
Your Answer: Client has a flat affect.
Correct Answer: Caregiver will bathe the client
only once a week.
Rationale: For the elderly, some hygiene
measures might not be needed or desirable in the
same frequency as for younger adults. However,
bathing only once weekly is not likely to be
sufficient. Unhappiness with living arrangements
and a flat affect are not evidence of mistreatment.
Recognition of challenges with care giving does not
mean mistreatment has occurred.
Nursing Process: Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
8.
Mistreatment that occurs in nursing homes and is
directed toward the elderly often is due to:
Your Answer: Staff’s lack of interest in the
elderly as individuals.
Correct Answer: Low wages and heavy workloads
of the nursing assistants.
Rationale: Individuals who have few skills and
inadequate education in the complex care needs of
the elderly, along with accompanying low wages
and heavy workloads, might mistreat the elderly out
of simple frustration. on the arm. Nursing Process: Assessment
Nursing Process: Evaluation Cognitive Level: Analysis
Cognitive Level: Analysis NCLEX-RN Test Plan: Psychosocial Integrity
NCLEX-RN Test Plan: Safe, Effective Care
Environment An elderly client whose middle-age daughter
________________________________________ recently died of breast cancer now complains of
9. mild abdominal pain, five-pound weight loss,
A nurse who plans to do research on caregiver insomnia, and fatigue. When no physiological cause
strain in spouses of homebound elderly with can be found, the nurse suspects these are
cognitive impairment due to dementia is most likely symptoms of:
to choose which theory of elder mistreatment to Your Answer: Hypochondria.
guide the study? Correct Answer: Normal grieving.
Your Answer: Situational theory
Rationale: Physiological symptoms are a
Rationale: Situational theory examines the normal part of grieving, particularly in the early
burdens of caregiving and the ability of the phases. In the absence of pathology, these are signs
caregiver to meet the needs and demands of the of normal grieving. Denial, spiritual distress, and
elderly individual. Mistreatment can result when the hypochondria usually do not manifest themselves
situation becomes overwhelming for the caregiver. with physical symptoms.
The other theories do not relate to caregiver strain. Nursing Process: Evaluation
Nursing Process: Planning Cognitive Level: Analysis
Cognitive Level: Application NCLEX-RN Test Plan: Psychosocial Integrity
NCLEX-RN Test Plan: Health Promotion and ________________________________________
Maintenance 2.
________________________________________ A nurse who works effectively with elderly clients
10. who are dying and their families recognizes that:
Which of the following observations is indicative of Your Answer: At least some pain accompanies
physical mistreatment? most deaths.
Your Answer: Downcast eyes Correct Answer: The nurse must be comfortable
Correct Answer: Dislocated shoulder with her own concerns and feelings about death.

Rationale: This is the only listed physical sign. Rationale: Nurses and other healthcare
A dislocated shoulder can occur with a violent jerk providers who are comfortable with their own
understanding of death can be effective when
working with the dying, rather than bringing their
conflicted feelings to a stressful situation. Unless
the nurse has used some critical thinking to look at
and investigate her feelings and understandings,
they might conflict with those of the client. Many
people are indeed afraid of dying, especially if pain
might occur. However, pain is not inevitably
associated with death. Hospice might not be
appropriate or possible for many individuals.
Nursing Process: Analysis
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
3.
It is important for a nurse to understand the
grieving process because:
Your Answer: It assists the nurse to
understand the dynamics of grieving.
Rationale: Grief is unique to each individual
and family and culture. By understanding the
grieving process, the nurse will recognize the social,
cultural, and physiological dynamics present during
grieving. There is no optimal order in which
individuals must move through the grieving process.
Nursing Process: Evaluation
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
4.
The goal of nursing interventions for a bereaved
elderly person is to:
Your Answer: Assist the bereaved individual to
achieve a healthy adjustment to the loss.
Rationale: The goal of grieving is to adjust to
the loss in a time and manner that is culturally
acceptable to the individual who experienced the
loss. There is no timetable that must be met, no
defined way to achieve the goal. An intervention to
progress toward the goal is verbalization about the
loved one. Teaching is a nursing goal and is not
client-centered.
Nursing Process: Planning
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
5.
An elderly person in end-stage renal disease is
admitted to a nursing home for palliative care.
Nursing interventions will be:
Your Answer: Ambulation as desired.
Correct Answer: Pain relief.
Rationale: The purpose of palliative care is
pain relief when no additional treatment is desired
or available. Comfort measures direct the primary
nursing intervention, and can include medications or
complementary therapies, such as massage.
Individuals receiving palliative care are not
candidates for CPR. Urine output is not expected in
end-stage renal disease.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
6.
A nurse is uncomfortable discussing spiritual
concerns with a dying client. The most helpful action
for the client would be for the nurse to plan to:
Your Answer: Request a member of the
pastoral care staff visit the client.
Rationale: Pastoral care is available at most
sites, and if a nurse is uncomfortable with spiritual
issues, the pastoral care services might be better
able to meet the spiritual needs of the client. A
nurse would plan to get education, rather than
counseling, on how to meet the needs of dying
clients. Discomfort with a situation is not a reason
for asking to be removed from caring for that client.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
7.
When opioids are prescribed for pain at the end of
life, the nurse should understand that:
Your Answer: Opioids most likely will be a PRN
order.
Correct Answer: Side effects still must be treated.
Rationale: Opioids are the gold standard of
pain relief; however, side effects like constipation
are common, and must be treated to provide
comfort to the client. A client can be on opioids for a
long time before death; they are most effective
when given on an around-the-clock schedule. A
client may be on other medications concurrently.
Nursing Process: Evaluation
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
8.
A priority nursing intervention for an elderly person
who is dying and experiencing anxiety is to:
Your Answer: Allow the client time alone to
conduct a life review.
Correct Answer: Assist the individual to identify
fears.
Rationale: People who are dying have many
fears, including pain, being left alone, or being
forgotten. The nurse who can help the client identify
those fears then can work with the client to explain
what can be done to alleviate the concerns. Some
time alone might be appropriate, but many times, it
increases anxiety. Contacting family might be
appropriate, but not until after the nurse has
determined with the client that it will be helpful.
Merely explaining that anxiety is common, without
further intervention, is not the best action the nurse
can take.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
9.
Which of the following statements, if made by a
dying client, would indicate that spiritual needs
most likely are being met? The individual states
that:
Your Answer: “There have been many positive
things about my life, and I have hope.”
Rationale: When an individual’s spiritual
needs have been met, the person can be expected
to express feelings of satisfaction with one’s life and
develop a new understanding of hope. Many people
who do not subscribe to particular spiritual beliefs
might not fear pain, and many have an appreciation
for family. Some religious groups do not believe in
an afterlife.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
10.
When an elderly client expresses a wish to forgo
additional treatment for cancer and to die, a priority
action of the nurse would be:
Your Answer: Explore the client’s
understanding of the consequences of such a
decision.
Rationale: When respecting a client’s
autonomy, the nurse recognizes that the client has
a right to make such a decision. It is important to
make sure the client understands what such a
decision means about the outcome of the disease
process. At some point, the physician and family
should be notified, but only after discussion with the
client affirms the decision. The role of the nurse is to
support a client, not suggest what the client should
do.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Psychosocial Integrity
When administering medication to an elderly
hospitalized client, the nurse should be aware that
there is an increased possibility of drug toxicity due
to which of the following age-related changes?
Your Answer: Decreased filtration and
excretion of drug metabolites through the renal
system
Rationale: Glomerular filtration and creatinine
clearance begin to decline in middle age, and can
be significantly lower in most elderly, posing a risk
of greater drug toxicity. There is no increase in
protein-binding sites or circulating body fluids in the
elderly. Production of enzymes also is not decreased
with aging.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
2.
Which of the following indicates that an elderly
client has been affected by polypharmacy?
Your Answer: Medications are used to
counteract side effects of currently prescribed
medications.
 Rationale: Polypharmacy means that multiple
medications have been prescribed. When
medications are prescribed to counteract side
effects of other medications, it is an indication that
a total review of medications should occur to
determine the optimum medications and dosages
with the fewest side effects. Lack of improvement in
a condition might mean another evaluation is
warranted. Healthcare providers need to determine
the possible benefits and risks in prescribing or not
prescribing any given medication.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
3.
In assessing use of over-the-counter (OTC)
medications, which of the following questions will
the nurse want to ask the elderly client?
Your Answer: “Who pays for the medication?”
Correct Answer: “How does this medication help
you?”
Rationale: It is important to assess how the
medication helps the client or how the client feels it
is helpful. Payment or brand selections are up to the
client, and might be related to other considerations.
Other treatment strategies do not relate to OTC
medications.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
4.
What is frequently a contributing factor to the
elderly using multiple medications?
Your Answer: Increased challenges in
compliance with medication regimens
Correct Answer: Healthcare providers’ failure to
coordinate medication regimens
Rationale: The elderly client might be under
the care of multiple healthcare providers who are
unaware of the medications the other providers
have prescribed. The elderly should be encouraged
to maintain a list of medications, dosages,
frequency, and prescriber information to share with
all healthcare providers. The greater the number of
medications the client is taking, the higher the
likelihood of side effects and decreased compliance
with medication regimens.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
5.
Anticholinergic effects of antipsychotic medications
in the elderly are associated with:
Your Answer: Cognitive impairment.
Correct Answer: Difficulty with voiding.
Rationale: Anticholinergic effects commonly
are found in prescribed medications, and frequent
side effects (urinary retention, dry mouth, blurred
vision, decreased peristalsis, etc.) occur in the
elderly, so the nurse needs to assess for those side
effects with elderly clients.
Nursing Process: Assessment
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
6.
Gastritis in the elderly frequently has been
associated with:
Your Answer: Beta blockers.
Correct Answer: Low doses of aspirin.
Rationale: Aspirin is highly irritating to the
stomach, and can lead to heartburn or gastritis,
even with low-dose or enteric coating, if it is not
taken properly. Other types of medications listed
are not frequently associated with gastritis.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
7.
General guidelines regarding prescribing
medications for the elderly clients are:
Your Answer: Start low and go slow.
Rationale: This rule of thumb is followed to
prevent toxic effects and adverse drug reactions.
The usual practice is to start with the lowest dose
possible and evaluate regularly to see if symptoms
subside or the condition improves; the dose is
increased only if necessary.
Nursing Process: Planning
Cognitive Level: Comprehension
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
8.
The ultimate goal of prescribing antipsychotic
medications for the elderly is:
Your Answer: To relieve stress on family
members who are caregivers.
Correct Answer: To improve the quality of life.
Rationale: Antipsychotic medications should
be prescribed with great caution in the elderly and
should be viewed only as short-term therapy to
improve quality of life.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
9.
An elevated level of a highly protein-bound
medication might be a result of which
pharmacokinetic alteration in the elderly?
Your Answer: Increased CPK
Correct Answer: Decreased serum albumin
Rationale: Decreased serum albumin results
in greater amounts of the unbound proportion of
protein-bound medications. This can result in toxic
levels, because the unbound portion is available to
produce effects. The other substances do not affect
protein-bound medications.
Nursing Process: Planning
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
10.
The area in which the nurse may have the greatest
effect on medication use in the elderly is:
Your Answer: Screening for side effects.
Correct Answer: Client education.
Rationale: Teaching clients and families about
safe practices and information about side effects
will ensure medications that are effective are used
correctly and have the fewest effects. The nurse
may encourage alternative therapies if they do not
affect medication compliance or increase the risk of
side effects. Monitoring clients is important, but
teaching is likely to have the greatest impact on
clients.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
11.
When developing a teaching plan for an elderly
client newly diagnosed with hypertension, the nurse
realizes that the most effective teaching strategy is:
Your Answer: Sharing the Web address of the
American Heart Association.
Correct Answer: Providing oral instructions along
with a written copy to take home.
Rationale: Oral instruction allows the nurse to
answer questions and to verify client understanding
of instructions. Written information is for the client
or family to review if they have additional questions
or need more information. Clients might seek other
sources of information, but it is the responsibility of
the nurse to provide information that is
understandable to the client.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
12.
An elderly client asks why he seems to respond
differently to some medications than he did in the
past. The nurse should keep in mind that:
Your Answer: In the elderly, an adverse drug
reaction can occur even after the medication has
been discontinued.
Rationale: Due to the pharmacokinetics and
pharmacodynamics in the elderly, it is possible to
have adverse reactions during or following
discontinuation of medication therapy. Glomerular
filtration is decreased in the elderly, so there might
be more side effects.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
13.
If an elderly client tells the nurse about medications
from an internet site with NAPB VIPPS (National
Association of Boards of Pharmacy, Verified Internet
Pharmacy Practice Site), the nurse can be fairly
certain that:
Your Answer: The client has financial need.
Correct Answer: The site meets state and federal
requirements.
Rationale: Increasing use of the internet by
the elderly and others to purchase medications has
led to federal and state regulations that assure
safety for the consumer. Medications purchased
from the internet are not necessarily from foreign
countries, and do not necessarily mean the client is
experiencing financial distress.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
You are the nurse assigned to perform an eye
assessment on an 80-year-old client. Which of the
following findings during the assessment is
considered normal?
Your Answer: Absence of the red reflex
Correct Answer: Equal pupillary constriction in
response to light
Rationale: Pupils are small in old age, and the
pupillary light reflex can be slowed, but pupillary
constriction should be symmetrical. There should be
a red reflex, and the eyelids and conjunctivae
should not be edematous or inflamed.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk
________________________________________
2.
Which of the following physiologic changes would be
expected in a patient with presbyopia?
Your Answer: Loss of lens elasticity
Rationale: The lens loses elasticity or
pliability, decreasing its ability to change shape in
order to accommodate for near vision. Response 4
is indicative of cataracts, 3 is myopia, and 1 is due
to corneal changes.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
3.
A patient has a question about a recent eye exam.
Which of the following statements would be an
accurate response to inquiry?
Your Answer: "The lens is normally
transparent."
Rationale: The lens is made of layers of
epithelial cells that are closely packed and
organized so that the lens is clear and transparent.
Hypermetropia is a shortened eyeball, and myopia
is an elongated eyeball. Refraction refers to bending
the light rays so they are focused at a certain point
on the retina.
Integrated Process: Teaching Learning
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
4.
A client comes to the office with a tentative
diagnosis of glaucoma, and is to have testing to
determine whether the anterior angle of the eye is
open or closed. The patient will require education
for which of the following examinations?
Your Answer: Retinography
Correct Answer: Slit-lamp inspection
Rationale: The slit-lamp inspection of the iris
is done to assess whether the anterior angle of the
eye is open or closed. This is part of a complete
dilated examination to inspect the optic nerve and
retina. Tonometry measures only the pressure
within the eye. Response 2 would be used to take
multiple x-rays of the eye tissue, and retinography
records the electrical activity of the eye.
Integrated Process: Teaching Learning
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
5.
A patient with glaucoma has medication prescribed
to decrease intraocular pressure. Which of the
following medication should be questioned by the
nurse?
Your Answer: Artificial tears
Rationale: Timoptic, levobunolol, and
pilocarpine are drugs usually prescribed for patients
with glaucoma and increased intraocular pressure
(IOP). Artificial tears are usually prescribed for
persons with "dry eyes."
Integrated Process: Nursing Process; Evaluation
Cognitive Level: Evaluation
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological and Parenteral Therapies
________________________________________
6.
A client with history of glaucoma was diagnosed by
the community nurse as experiencing Visual
Sensory/Perceptual Alterations R/T increased
intraocular pressure. The plan of care should focus
on:
Your Answer: Encouraging compliance with
drug therapy to prevent loss of vision.
Rationale: Management of glaucoma involves
lowering the intraocular pressure to cease drainage
to the optic nerve and further vision loss. Therapy
involves medications to decrease intraocular
pressure. It is critical that the patient understand
the importance of compliance with the medication
regimen. Glaucoma needs to be controlled to
prevent damage that cannot be reversed. Pain is
considered an emergency, so if it was identified, the
patient would need immediate intervention. Loss of
peripheral vision is a concern, but the priority is to
encourage the patient to be compliant with
medications to prevent further damage to the
vision.
Integrated Process: Nursing Process;
Implementation
Cognitive Level: Synthesis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
7.
A 76-year-old client tells the nurse that she notices
that she is having trouble hearing, especially in
large groups. She continues, saying she cannot
always tell where the sound is coming from, and the
words often sound "mixed up." The nurse should
suspect which of the following as the cause for this
change?
Your Answer: Nerve degeneration in the inner
ear
Rationale: Hearing loss is common in older
adults. Changes in the inner ear involve atrophy of
the organ of corti and cochlear, and degeneration of
the stria vascularis. This is a gradual hearing loss
that affects the auditory nerve, which makes words
sound garbled, and the ability to localize sound is
also impaired. The result is that communication
dysfunction is accentuated when background noise
is present. Responses 1, 2, and 4 would not affect
the sensorineural component of hearing.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Adaptation
________________________________________
8.
You are the nurse assigned to care for an elderly
client. While assessing the ears of the patient, you
observed dry, hard cerumen developing in the ear
canal. Which of the following actions should you
take?
Your Answer: Irrigate the ear canal with a
mixture of hydrogen peroxide and normal saline.
Correct Answer: Document finding and report
your concern to the physician.
Rationale: Cerumen or earwax produced by
the ceruminous glands is a normal finding in the ear
canal. However, in the older adult, cerumen tends to
be dryer and harder, and accumulates in the ear
canal due to decreased activity of the apocrine
glands. Hearing will become impaired if the
cerumen accumulates to impact the canal. Irrigation
should be tried after other attempts fail. Therefore,
documentation and reporting to the primary care
provider will help avoid unnecessary alteration in
hearing.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity; Basic
Care and Comfort
________________________________________
9.
During a hearing assessment, the nurse finds that
sound lateralizes to the client's left ear with the Rationale: Presbycusis is hearing loss
Weber and Rinne tests. What should the nurse associated with aging, and affects approximately
conclude from this finding? The patient has: 75% of people over the age 60. Loss of hair cells in
Your Answer: A conductive hearing loss in the the cochlea (sensory loss) and degradation of
right ear. neurons (neural loss) result in this form of hearing
Correct Answer: Either a sensorineural or loss. Presbycusis occurs gradually, and usually is
conductive hearing loss. bilateral. Answer 3 describes a conductive hearing
loss.
Rationale: When caring for the older person, a Integrated Process: Nursing Process; Analysis
thorough history and physical of the person's Cognitive Level: Application
hearing is important to help determine the cause of NCLEX-RN Test Plan: Physiological Integrity;
hearing loss, which can be conductive, due to Reduction of Risk Potential
external aspect of the ear, or sensorineural, from an ________________________________________
inner ear problem. 11.
Both tests determine the degree of hearing loss, if An 84-year-old client is admitted to the hospital for
any. treatment of diabetes mellitus.
Integrated Process: Nursing Process; Assessment On initial interview, the patient reports having
Cognitive Level: Analysis difficulty hearing, and informs the nurse that she
NCLEX-RN Test Plan: Physiological Integrity: has too much ear wax. Because of the patient's age,
Reduction of Risk Potential which of the following questions is most important
________________________________________ for the nurse to ask the client in relation to her
10. hearing problem?
Which of the following is true of presbycusis? (Select Your Answer: "What type of diabetes mellitus
all that apply.) do you have?"
Your Answer: Dysfunction with the cochlea Correct Answer: "Have you ever experienced
and auditory nerve impacted cerumen?"
Correct Answers: Dysfunction with the cochlea
and auditory nerve Rationale: Because the hairs in the ear
become coarser during the aging process, retention
Ménière’s disease and tumors of wax is more of a cause of hearing loss in older
clients. Cerumen, if dry and hard, can impact the
Infections of the inner ear ear canal and interfere with hearing.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Analysis
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
12.
Which of the following drugs are not associated with
impairment? Select all that apply.
Your Answer: Gentamicin (Garamycin)
Correct Answers: Gentamicin (Garamycin)
Cis-platinum (Platinol)
Furosemide (Lasix)
Rationale: Digoxin (Lanoxin) causes vision
changes, but does not affect hearing.
Aminoglycosides such as gentamicin,
antineoplastics such as cis-platinum, diuretics such
as furosemide, antispasmodics such as baclofen,
and propranolol cause changes in hearing ability.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Pharmacological and Parental Therapies
________________________________________
13.
A patient has a normal sensory change that results
in diminished sense of taste. How would this be
documented?
Your Answer: Hypogeusia
Rationale: A diminished sense of taste is
referred to as hypogeusia. Odynophagia refers to
pain upon swallowing. Xerostomia refers to dry
mouth that occurs with salivary gland dysfunction.
Arthralgia refers to pain in a joint.
Integrated Process: Communication and
Documentation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
14.
A client has noticed a decrease in taste sensation.
Which of the following cranial nerves are most likely
involved?
Your Answer: CN IX and CN VII
Rationale: Cranial nerves VII and IX supply
sensation to the tongue.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
15.
A 78-year-old client is admitted to the Emergency
Department (ED) via emergency medical service
(EMS) with complaints of severe diarrhea with
resultant weakness and signs of dehydration.
Discussion with the significant other reveals that the
patient continually eats spoiled foods. Which of the
following might be most directly related to this
patient's behavior?
Your Answer: Damage to cranial nerve III
Correct Answer: Damage to cranial nerve I

Rationale: Although hyposmia (impaired
sense of smell) might be due to age-related
changes, it might also be the result of olfactory
nerve damage (cranial nerve I), since this nerve is
the sole innervation for smell. Cranial nerve II is
responsible for constriction of the pupils, and IV the
superior oblique muscle. Cranial II would affect
vision, but an intact CN I would allow the individual
to identify the odor of spoiled food accurately.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Physiological Adaptation
________________________________________
16.
In evaluating the functioning of a client's anterior
spinothalamic tract, the nurse is testing for:
Your Answer: Sense of position.
Correct Answer: Light touch sensation.
Rationale: It is the spinothalamic tract that
transmits light (crude) touch sensation.
Integrated Process: Evaluation
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Health Promotion and
Maintenance
The nurse is teaching a group of elderly women
about skin care. Which of the following would be
accurate to include in the content?
Your Answer: The dermis is completely
replaced every four weeks.
Correct Answer: The dermis contains nerves and
sensory receptors.
Rationale: The dermis, the second layer of the
skin, is made up of connective tissue, collagen, and
has resilient elastic tissue that allows the skin to
stretch. It is the thickest skin layer and also contains
fibroblasts, mast cells, and lymphocytes.
Integrated Process: Nursing Process; Planning
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Health Maintenance and
Promotion
________________________________________
2.
During the aging process, the hair can look gray or
white and begin to feel thin and fine. This is due to
decreased number of functioning:
Your Answer: Lymphocytes.
Correct Answer: Melanocytes.
Rationale: In the aging hair matrix, the
number of functioning melanocytes decreases, so
the hair looks gray or white and feels thin and fine.
The phagocytes, lymphocytes, and eosinophils are
cells important to the inflammatory response and
the immune system.
Integrated Process: Nursing Process: Analysis
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
3.
An 84-year-old patient's skin is assessed to be
wrinkled, thin, and dry. These findings should be
interpreted as related to:
Your Answer: Increased vascularity of the skin.
Correct Answer: Loss of elastin and a decrease in
subcutaneous fat.
Rationale: Several factors cause wrinkled,
thin, dry skin. These include gradual loss of elastin;
decreased subcutaneous fat; decreased number of
epithelial cells providing a barrier, causing
insensible loss of body fluids from the deeper layers
of the skin; a lifetime of environmental trauma to
the skin; increasing sedentary lifestyle; and
decrease in mobility.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
4.
A term used to describe discolored areas of aging
skin due to damage to capillaries is:
Your Answer: Actinic keratosis.
Correct Answer: Senile purpura.
Rationale: During the normal aging process,
the vascularity of the dermis decreases and
contributes to a paler complexion in the white-
skinned older person. The capillaries become
thinner and more easily damaged, leading to
bruised and discolored areas known as senile
purpura.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
5.
Which of the following is accurate about skin
cancer? Skin cancers that result primarily from sun
exposure are:
Your Answer: Hodgkin's disease.
Correct Answer: Basal cell carcinomas.
Rationale: Skin cancers that result primarily
from sun exposure are basal cell carcinoma (BCC),
squamous cell carcinoma (SCC), and malignant
melanoma (MM). The risk for squamous cell
carcinoma is strongly associated with chronic sun
exposure but not with intermittent exposure.
Hodgkin's disease is a cancer of the lymphatic
system, and bronchogenic carcinoma is a lung
cancer. Actinic keratotic lesions are precancerous
skin lesions.
Integrated Process: Nursing Process; Analysis
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Risk Potential
________________________________________
6.
An elderly client is being assessed because of a
rough, scaly, erythematous papule on the patient's
body. Important teaching for this patient would
include that this is most likely a (an):
Your Answer: Erythematous actinic keratotic
lesions.

Rationale: Erythematous actinic keratotic
lesions are the most common type of precancerous
lesion. They appear as painful rough, scaly,
erythematous papules or plaque.
The acrochordon, seborrheic keratoses, and senile
lentigines do not become malignant.
Integrated Process: Teaching/Learning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity;
Reduction of Potential Risk
________________________________________
7.
Which of the following factors affect skin tolerance
and enhance the occurrence of pressure ulcers?
(Select all that apply.)
Your Answer: Decreased serum albumin
Correct Answers: Shearing
Increased body weight
Dramatic loss of collagen
Rationale: Shearing, or the sliding of parallel
surfaces against each other, occurs most commonly
when the client slides down in the bed. Increased
body weight and dramatic loss of collagen also
could increase the risk of pressure ulcers. An
increased serum albumin would not create a skin
problem, but a decreased serum albumin would
indicate a low level of protein stores and increased
risk for impaired skin integrity.
Integrated process: Nursing Process; Analysis
Cognitive level: Application
NCLEX-RN Test Plan: Physiological Integrity: Basic
Care and Comfort
________________________________________
8.
In order to prevent shearing injury to a 50-year-old
terminally ill patient who is high-risk for skin
damage, which of the following measures would be
effective? (Select all that apply.)
Your Answer: Keeping the patient's skin clean
and dry
Correct Answers: Encouraging the client to use a
trapeze bar
Keeping the patient's skin clean and dry
Rationale: The high-risk patient for skin
damage will need frequent position changes and
clean, dry skin. A trapeze bar, turning sheet, and
transfer board are specific interventions that can be
used to prevent shearing injury to the skin.
Integrated Process: Nursing Process; Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity; Basic
Care and Comfort
________________________________________
9.
Which of the following statements is an accurate
description for the inflammatory phase of wound
development? The inflammatory phase:
Your Answer: Begins soon after injury and
continues for up to three weeks.
Correct Answer: Is characterized by redness,
heat, pain, and edema or swelling.
Rationale: The inflammatory phase of healing
is characterized with the classic symptoms of
inflammation, such as redness, heat, pain, and
edema or swelling. The other answers relate to the
different phases of wound development.
Integrated Process: Nursing Process; Assessment
Cognitive Level: Knowledge
NCLEX-RN Test Plan: Physiological Integrity; Basic
Care and Comfort
________________________________________
10.
A patient develops severe inflammation of the lower
extremity. Which of the following foods should be
included in the diet for this patient?
Your Answer: Carrots and other yellow
vegetables
Correct Answer: Citrus fruits, protein, and fluids
Rationale: The diet of the client with
inflammation should be high in vitamin C, to aid in
the synthesis of collagen; protein, to aid in the
formation of blood cells and tissue; and fluids, to
remove metabolic waste and rehydrate the client.
Integrated Process: Nursing Process; Planning
Cognitive Level: Synthesis
NCLEX-RN Test Plan: Physiological Integrity; Basic
Care and Comfort
1.
How do the Scope and Standards of Gerontological
Nursing Practice (ANA, 2004) guide professional
nursing practice?
Your Answer: They are the legal standard for
gerontological nursing practice.
Rationale: The Scope and Standards deal with
the professional obligations of the nurse when
caring for the elderly; they are not intended as
assessment measures. Boundaries of practice are
addressed in the Nurse Practice Act of each state.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
2.
When an elderly client refuses to take the usual
morning medications or get out of bed, the nurse
must deal with ethical issues related to:
Your Answer: Veracity.
Correct Answer: Autonomy.
Rationale: Autonomy relates to the client’s
right to self-determination and right to make
decisions. Beneficence has to do with doing good,
veracity deals with being truthful, and justice has to
do with being fair.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
3.
What is the advanced practice registered nurse
(APRN) who is board certified (BC) in gerontology
most likely able to do?
Your Answer: Serve as an administrator of a
nursing home.
Correct Answer: Be employed as a nurse
practitioner.
Rationale: This role requires a graduate
degree, and those with Master’s degrees may seek
board certification. Case managers are not required
to be nurses, and nursing home administrators are
required to have specialized education and
certification in that discipline. Researchers are
qualified to develop and test theories.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
4.
What information will the nurse use to respond to
the elderly client who states, “I will never go to a
nursing home; I am going to die at home”?
Your Answer: “Most people will need a brief
stay in a nursing home at some time in their lives.”
Rationale: Current data indicate that over
40% of people will need at least a brief stay in a
nursing home to recover from surgery, illness, or
injury at some point in their lives. Other responses
do not provide correct or supportive information.
Nursing Process: Implementation
Cognitive Process: Application
NCLEX-RN Test Plan: Psychosocial Integrity
________________________________________
5.
With what part of the functional health pattern
assessment is the nurse most concerned when an
elderly female is admitted to the hospital with deep
jaundice?
Your Answer: Nutritional-metabolic
Rationale: Jaundice is caused by obstruction
of one of the biliary ducts, and most frequently
results in appetite changes. Health perception-
health maintenance and coping-stress management
do not address functional changes. Elimination is
not a priority concern when jaundice is present.
Nursing Process: Assessment
Cognitive Level: Application
NCLEX-RN Test Plan: Health Promotion and
Maintenance
________________________________________
6.
An appropriate goal for a elderly male who had a
CVA with right-sided hemiplegia and a nursing
diagnosis of impaired self care management would
be:
Your Answer: Requests that wife shave him
daily in the morning.
Correct Answer: Communicates need to use the
urinal.
Rationale: Requesting to use the urinal is
indicative of self-care. Other options do not deal
with the client’s managing his physical care by
himself.
Nursing Process: Planning
Cognitive Level: Implementation
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
7.
The nurse expects to use the nursing process when
first meeting an elderly client in the clinic. What is
the priority nursing action before initiation of the
nursing process?
Your Answer: Ascertain the chief complaint.
Correct Answer: Establish rapport with the client.
Rationale: Effective use of the nursing
process is dependent on the nurse first making the
client feel comfortable and creating an environment
of trust. Other actions would be appropriate after
rapport is established.
Nursing Process: Planning
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment
________________________________________
8.
After providing basic care for an elderly client, the
nurse concludes that hydration is a priority need.
This decision represents which step of the nursing
process?
Your Answer: Assessment
Correct Answer: Planning
Rationale: Setting goals or outcomes is the
planning phase of the nursing process, and should
involve the client. Assessment must occur prior to
setting goals. Implementation is based on the
outcomes; evaluation follows implementation and
determines if outcomes have been achieved.
Nursing Process: Planning
Cognitive Level: Application
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
9.
Allowing an elderly female hospitalized for surgical
repair of a fractured hip to take her medications
with her morning cup of coffee is an example of:
Your Answer: Providing culturally acceptable
care.
Correct Answer: An appropriate nursing
intervention.
Rationale: Clients can select the fluid of
choice for taking medications unless there is a
specific known contraindication for a particular
medication. This intervention is not related to
cultural practices or to evidence-based practice.
Case management deals with planning for the
hospital stay and post-hospital care needs.
Nursing Process: Implementation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Physiological Integrity
________________________________________
10.
Current demographic trends project a steadily
increasing elderly population. What research focus
recognizes this trend?
Your Answer: Studies that demonstrate the
best timing to introduce the topic of durable powers
of attorney for healthcare
Correct Answer: Studies that examine the role
strain of caregivers for the elderly

Rationale: Increasing numbers of elderly

mean there will be increasing numbers of caregivers
who will experience stress. Studies need to be done
to find ways to reduce the stress those individuals
experience, whether they are family members or
healthcare professionals. Other options deal with
specific situations that are not related to population
trends.
Nursing Process: Evaluation
Cognitive Level: Analysis
NCLEX-RN Test Plan: Safe, Effective Care
Environment